Basic Information
| Provider Information | |||||||||
| NPI: | 1366407611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | NICOLA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TABASSO | ||||||||
| OtherFirstName: | NICOLA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 224 STRAWBRIDGE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080574602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566774000 | ||||||||
| FaxNumber: | 8562343014 | ||||||||
| Practice Location | |||||||||
| Address1: | 1224 TILTON RD | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082251809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099261161 | ||||||||
| FaxNumber: | 6096263223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | 40QA00572700 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | 40QA00572700 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 40QA00572700 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.