=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255687083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE P DEMETRESCU PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2012
-----------------------------------------------------
Last Update Date | 07/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 MAIN AVE S SUITE 111
-----------------------------------------------------
City | NORTH BEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98045-8139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-888-3347
-----------------------------------------------------
Fax | 425-888-3348
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 MAIN AVE S SUITE 111
-----------------------------------------------------
City | NORTH BEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98045-8139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-888-3347
-----------------------------------------------------
Fax | 425-888-3348
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | PT60283444
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------