Healthcare Provider Details

I. General information

NPI: 1700568854
Provider Name (Legal Business Name): NICHOLAS DELLAFLORA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 DIEDERICH BLVD
RUSSELL KY
41169-1719
US

IV. Provider business mailing address

112 HILLCREST CT
RUSSELL KY
41169-1401
US

V. Phone/Fax

Practice location:
  • Phone: 606-833-9444
  • Fax: 606-833-9442
Mailing address:
  • Phone: 614-557-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT020669
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number009006
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: