Basic Information
| Provider Information | |||||||||
| NPI: | 1346371788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANGELOS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 UNICORN PARK DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018013342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817821300 | ||||||||
| FaxNumber: | 7817821350 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 PRESIDENTIAL WAY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018011100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817821300 | ||||||||
| FaxNumber: | 7817821350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 15862 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 15862 | 01 | MA | STATE LICENSE NUMBER | OTHER |