Healthcare Provider Details

I. General information

NPI: 1700057437
Provider Name (Legal Business Name): NICKLOS MICHAEL MARKEY APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 02/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

67 GLENWOOD RD
SOUTH WINDSOR CT
06074-3027
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2000
  • Fax:
Mailing address:
  • Phone: 860-648-2620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number003546
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number003546
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: