MEDICARE: TAMMY R NICKEL MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	26328	CA

General Provider Information

NPI Number	:	1114259140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY R NICKEL MPT

Provider Business Mailing Address
First Line	:	PO BOX 25
Second Line	:
City	:	POWAY
State	:	CA
Zip	:	92074-0025
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16885 W BERNARDO DR
Second Line	:	SUITE 380A
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-1618
Country	:	US
Telephone Number	:	858-722-3484
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2010
Last Update Date	:	02/01/2010

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