Healthcare Provider Details

I. General information

NPI: 1063400547
Provider Name (Legal Business Name): DONNA NICKLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 EISENHOWER DR SUITE 200
PARAMUS NJ
07652-1401
US

IV. Provider business mailing address

80 EISENHOWER DR SUITE 200
PARAMUS NJ
07652-1401
US

V. Phone/Fax

Practice location:
  • Phone: 201-843-2800
  • Fax: 973-939-0273
Mailing address:
  • Phone: 201-843-2800
  • Fax: 973-939-0273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MB03792500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: