Provider Demographics
NPI:1992798607
Name:DEVERTEUIL-WAGGONER, NICOLE J (PT)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:J
Last Name:DEVERTEUIL-WAGGONER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 NW 101ST AVE
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-1235
Mailing Address - Country:US
Mailing Address - Phone:954-258-0415
Mailing Address - Fax:954-718-6046
Practice Address - Street 1:12341 NW 18TH ST
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33323-2122
Practice Address - Country:US
Practice Address - Phone:954-478-4648
Practice Address - Fax:954-530-5694
Is Sole Proprietor?:No
Enumeration Date:2005-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18177225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8728AMedicare ID - Type Unspecified