MEDICARE: MRS. NICHOLE E CLAYTON PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT26416	FL

General Provider Information

NPI Number	:	1386939528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICHOLE E CLAYTON PT, DPT

Provider Business Mailing Address
First Line	:	PO BOX 40767
Second Line	:	CREDENTIALING DEPARTMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32203-0767
Country	:	US
Telephone Number	:	904-376-3707
Fax Number	:	904-391-5807

Provider Business Practice Location Address
First Line	:	1845 TOWN CENTER BLVD STE 410
Second Line	:	CREDENTIALING DEPARTMENT
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-3361
Country	:	US
Telephone Number	:	904-621-0396
Fax Number	:	904-621-0397

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	02/04/2015

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