Healthcare Provider Details

I. General information

NPI: 1033939244
Provider Name (Legal Business Name): NICOLE DOMINIQUE JALANDONI VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2024
Last Update Date: 10/12/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 GALAXY DR NE STE 301
LACEY WA
98516-4754
US

IV. Provider business mailing address

6462 STEAMER DR SE
LACEY WA
98513-6230
US

V. Phone/Fax

Practice location:
  • Phone: 360-456-1444
  • Fax:
Mailing address:
  • Phone: 564-225-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT61432108
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: