Healthcare Provider Details

I. General information

NPI: 1932449832
Provider Name (Legal Business Name): NICOLE DANIELLE PUKAY-MARTIN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S FORT THOMAS AVE
FORT THOMAS KY
41075-2305
US

IV. Provider business mailing address

1000 S FORT THOMAS AVE
FORT THOMAS KY
41075-2305
US

V. Phone/Fax

Practice location:
  • Phone: 859-572-6280
  • Fax: 859-572-6223
Mailing address:
  • Phone: 859-572-6280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPP4162
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: