Basic Information
| Provider Information | |||||||||
| NPI: | 1053697847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOFMANN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M | ||||||||
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| OtherLastName: | LARNER | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 249 KEVIN LN | ||||||||
| Address2: | |||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190635923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844805322 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1023 E BALTIMORE PIKE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190635126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108911636 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT009776L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.