Healthcare Provider Details

I. General information

NPI: 1679947154
Provider Name (Legal Business Name): NICOLE WEISSERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15200 JOG RD SUITE B8
DELRAY BEACH FL
33446-1247
US

IV. Provider business mailing address

9873 LAWRENCE RD APT F101
BOYNTON BEACH FL
33436-3806
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-7171
  • Fax:
Mailing address:
  • Phone: 561-345-5728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA25954
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: