Basic Information
Provider Information | |||||||||
NPI: | 1295035376 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PALACAY | ||||||||
FirstName: | NIKKI ZENISA | ||||||||
MiddleName: | GISALA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2002 HARRISON ST | ||||||||
Address2: | APT A | ||||||||
City: | WICHITA FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 763094633 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549807226 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3101 10TH ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 763092103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9407660281 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2010 | ||||||||
LastUpdateDate: | 10/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1199770 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | J1-0002565 | DE | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.