Healthcare Provider Details

I. General information

NPI: 1790259810
Provider Name (Legal Business Name): GINA NICOLAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 FRANCINE AVE
MASSAPEQUA NY
11758-3613
US

IV. Provider business mailing address

46 FRANCINE AVE
MASSAPEQUA NY
11758-3613
US

V. Phone/Fax

Practice location:
  • Phone: 516-809-5818
  • Fax:
Mailing address:
  • Phone: 516-809-5818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343470
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberF343470-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: