Provider Demographics
NPI:1174540728
Name:SHANTI, NICOLLE H (PT)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:H
Last Name:SHANTI
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 1:5501 N ORACLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3829
Mailing Address - Country:US
Mailing Address - Phone:520-293-5551
Mailing Address - Fax:520-747-1633
Practice Address - Street 1:5501 N ORACLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3829
Practice Address - Country:US
Practice Address - Phone:520-293-5551
Practice Address - Fax:520-747-1633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4972225100000X
AZ4122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist