Healthcare Provider Details

I. General information

NPI: 1508532904
Provider Name (Legal Business Name): NICOLE CISEWSKI PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 BOYSON RD
HIAWATHA IA
52233-2313
US

IV. Provider business mailing address

2140 EDGEWOOD RD NW APT 2
CEDAR RAPIDS IA
52405-1036
US

V. Phone/Fax

Practice location:
  • Phone: 319-200-2004
  • Fax: 319-200-2009
Mailing address:
  • Phone: 715-572-8910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number107949
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: