Healthcare Provider Details

I. General information

NPI: 1295097673
Provider Name (Legal Business Name): NICOLE LYNN SNIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 HUSKIE LANE FEH BOCES
MALONE NY
12953
US

IV. Provider business mailing address

23 HUSKIE LANE FEH BOCES
MALONE NY
12953
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-5230
  • Fax:
Mailing address:
  • Phone: 518-483-5230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number198093081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: