Provider Demographics
NPI:1174953608
Name:KASSIAN, NICOLE DAWN (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:KASSIAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DAWN
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:343 E HEALD ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5225
Mailing Address - Country:US
Mailing Address - Phone:812-345-0071
Mailing Address - Fax:
Practice Address - Street 1:343 E HEALD ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5225
Practice Address - Country:US
Practice Address - Phone:812-345-0071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2014-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist