Healthcare Provider Details

I. General information

NPI: 1457420507
Provider Name (Legal Business Name): NICOLE ANN SEVERINO BS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 40TH AVE W SUITE 330
LYNNWOOD WA
98036-4612
US

IV. Provider business mailing address

19401 40TH AVE W SUITE 330
LYNNWOOD WA
98036-4612
US

V. Phone/Fax

Practice location:
  • Phone: 425-670-9987
  • Fax: 425-744-7233
Mailing address:
  • Phone: 425-670-9987
  • Fax: 425-744-7233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00009953
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: