Healthcare Provider Details

I. General information

NPI: 1275831695
Provider Name (Legal Business Name): NICOLE ELIZABETH ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 E GUN HILL RD
BRONX NY
10469-3720
US

IV. Provider business mailing address

1012 E GUN HILL RD
BRONX NY
10469-3720
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-8892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number487360-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: