Healthcare Provider Details

I. General information

NPI: 1972920304
Provider Name (Legal Business Name): NICOLE FAELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9131 QUEENS BLVD SUITE 604
ELMHURST NY
11373-5555
US

IV. Provider business mailing address

5937 60TH ST
MASPETH NY
11378-3233
US

V. Phone/Fax

Practice location:
  • Phone: 718-779-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number622010
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: