Provider Demographics
NPI:1255513263
Name:CASTILLO, NICOLE MARIE (MPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:KALAFUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3334 CAPITAL MEDICAL BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4470
Mailing Address - Country:US
Mailing Address - Phone:850-877-8174
Mailing Address - Fax:850-877-5636
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4470
Practice Address - Country:US
Practice Address - Phone:850-877-8174
Practice Address - Fax:850-877-5636
Is Sole Proprietor?:No
Enumeration Date:2007-11-30
Last Update Date:2015-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23698225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892592500Medicaid