Healthcare Provider Details

I. General information

NPI: 1962023796
Provider Name (Legal Business Name): NICOLE ANN STOREY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 11/08/2020
Certification Date: 11/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 ALBANY SHAKER RD STE 101
LATHAM NY
12110-1468
US

IV. Provider business mailing address

920 ALBANY SHAKER RD STE 101
LATHAM NY
12110-1468
US

V. Phone/Fax

Practice location:
  • Phone: 518-533-6502
  • Fax:
Mailing address:
  • Phone: 518-533-6502
  • Fax: 518-533-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number009212
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number009212
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: