Basic Information
| Provider Information | |||||||||
| NPI: | 1386169605 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSCEMA | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 S HARBOR CITY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217257225 | ||||||||
| FaxNumber: | 3218025811 | ||||||||
| Practice Location | |||||||||
| Address1: | 4311 NORFOLK PKWY STE 116 | ||||||||
| Address2: | |||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329048617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218025816 | ||||||||
| FaxNumber: | 3218025811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2017 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT35179 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40QA01736300 | 01 | NJ | LICENSE # | OTHER |