Healthcare Provider Details

I. General information

NPI: 1073949137
Provider Name (Legal Business Name): NICOLE FIDALIO M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3938 213TH ST
BAYSIDE NY
11361-2055
US

IV. Provider business mailing address

3938 213TH ST
BAYSIDE NY
11361
US

V. Phone/Fax

Practice location:
  • Phone: 917-579-0790
  • Fax:
Mailing address:
  • Phone: 917-579-0790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: