Basic Information
| Provider Information | |||||||||
| NPI: | 1508447624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRESENKO | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 306393 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372306393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153731350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 118 MARKET PLACE CIR STE D | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403247401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593001335 | ||||||||
| FaxNumber: | 8593107190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2021 | ||||||||
| LastUpdateDate: | 04/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.