Healthcare Provider Details

I. General information

NPI: 1174436687
Provider Name (Legal Business Name): NIKOLE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKOLE KOMAND

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BAYVIEW AVE
STONINGTON CT
06378-1142
US

IV. Provider business mailing address

633 NORWICH RD
PLAINFIELD CT
06374-1730
US

V. Phone/Fax

Practice location:
  • Phone: 860-249-1030
  • Fax:
Mailing address:
  • Phone: 610-741-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12437
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: