=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023564663
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE FONTES DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 12/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 WAMPANOAG TRAIL SUITE 403
-----------------------------------------------------
City | EAST PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02915-2237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-270-8770
-----------------------------------------------------
Fax | 401-270-8772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 RICHMOND SQ STE 200
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02906-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-433-4172
-----------------------------------------------------
Fax | 401-433-0612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT02921
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------