Healthcare Provider Details

I. General information

NPI: 1942878269
Provider Name (Legal Business Name): ROXANE NICHOLSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 10/21/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 VANBUREN STREET
NEWARK NY
14513
US

IV. Provider business mailing address

508 VIENNA ST LOT 13
NEWARK NY
14513-9160
US

V. Phone/Fax

Practice location:
  • Phone: 315-331-7741
  • Fax:
Mailing address:
  • Phone: 585-966-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number016024-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number016024-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: