Provider Demographics
NPI:1578541025
Name:LUNDY, NICOLE L (DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:LUNDY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:FREDERICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:43 SHUFELT RD STOP 4
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12037-3514
Mailing Address - Country:US
Mailing Address - Phone:518-470-5804
Mailing Address - Fax:
Practice Address - Street 1:98 GREEN ST STE 2
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2353
Practice Address - Country:US
Practice Address - Phone:518-470-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ47401Medicare ID - Type Unspecified