Healthcare Provider Details

I. General information

NPI: 1447183496
Provider Name (Legal Business Name): JESSICA NICOLE NICKLO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 TROY SCHENECTADY RD STE 224
LATHAM NY
12110-2490
US

IV. Provider business mailing address

809 24TH ST
WATERVLIET NY
12189-2023
US

V. Phone/Fax

Practice location:
  • Phone: 518-269-4700
  • Fax:
Mailing address:
  • Phone: 518-248-1389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number360001
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: