Healthcare Provider Details

I. General information

NPI: 1043576036
Provider Name (Legal Business Name): JAMIE LYNN NICK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JAMIE LYNN WILSON PT

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 W 23RD ST SUITE 1
ERIE PA
16506-5802
US

IV. Provider business mailing address

4950 W 23RD ST SUITE 1
ERIE PA
16506-5802
US

V. Phone/Fax

Practice location:
  • Phone: 814-459-2755
  • Fax: 814-456-4873
Mailing address:
  • Phone: 814-459-2755
  • Fax: 814-456-4873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT020926
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: