Healthcare Provider Details

I. General information

NPI: 1871889105
Provider Name (Legal Business Name): NICOLE BRIANNA CERKLEWICH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 STATE ROUTE 11
CHAMPLAIN NY
12919-4966
US

IV. Provider business mailing address

9 CAREY RD
QUEENSBURY NY
12804-7880
US

V. Phone/Fax

Practice location:
  • Phone: 518-298-2691
  • Fax: 518-298-8421
Mailing address:
  • Phone: 518-761-0300
  • Fax: 518-824-2388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number272368
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier03921895
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: