Healthcare Provider Details

I. General information

NPI: 1619628260
Provider Name (Legal Business Name): DAPHNE NICOLAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/23/2023
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRADHURST AVE
HAWTHORNE NY
10532-2140
US

IV. Provider business mailing address

11 OSBORNE AVE
NORWALK CT
06855-1806
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: