Basic Information
| Provider Information | |||||||||
| NPI: | 1003160896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLONE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ALYSON | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 ORTHOPAEDIC PL | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048250540 | ||||||||
| FaxNumber: | 9048252490 | ||||||||
| Practice Location | |||||||||
| Address1: | 3055 COUNTY ROAD 210 W STE 110 | ||||||||
| Address2: | |||||||||
| City: | ST JOHNS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048250540 | ||||||||
| FaxNumber: | 9048252490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2012 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT27401 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.