Provider Demographics
NPI:1992248199
Name:RAYSON, NICOLE EARLENE (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:EARLENE
Last Name:RAYSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:EARLENE
Other - Last Name:BOOHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 WILLOW VALLEY LAKES DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW STREET
Mailing Address - State:PA
Mailing Address - Zip Code:17584-9051
Mailing Address - Country:US
Mailing Address - Phone:717-464-6861
Mailing Address - Fax:717-464-8444
Practice Address - Street 1:900 WILLOW VALLEY LAKES DR
Practice Address - Street 2:
Practice Address - City:WILLOW STREET
Practice Address - State:PA
Practice Address - Zip Code:17584-9051
Practice Address - Country:US
Practice Address - Phone:717-464-6861
Practice Address - Fax:717-464-8444
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT025416225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA396818Medicare PIN