Healthcare Provider Details

I. General information

NPI: 1568366276
Provider Name (Legal Business Name): NICOLE WOODWARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE GARY

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 RIVER ST
CHATEAUGAY NY
12920-2002
US

IV. Provider business mailing address

107 SANCOMB RD
CHATEAUGAY NY
12920-2603
US

V. Phone/Fax

Practice location:
  • Phone: 518-497-6611
  • Fax:
Mailing address:
  • Phone: 518-651-6076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number343356
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: