Provider Demographics
NPI:1023257144
Name:GARNER, NICOLE RENEE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:GARNER
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:3311 TOLEDO TER STE A1
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-4136
Practice Address - Country:US
Practice Address - Phone:301-853-0093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22786OtherMARYLAND LICENSE NUMBER
94948501OtherCAREFIRST MARYLAND
46950038OtherCAREFIRST NCA
94948502OtherCAREFIRST MARYLAND
22786OtherMARYLAND LICENSE NUMBER