Healthcare Provider Details

I. General information

NPI: 1346538873
Provider Name (Legal Business Name): NICOLE GEDDES LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BELLPORT AVE
MEDFORD NY
11763-2219
US

IV. Provider business mailing address

225 BELLPORT AVE
MEDFORD NY
11763-2219
US

V. Phone/Fax

Practice location:
  • Phone: 631-924-2585
  • Fax:
Mailing address:
  • Phone: 631-924-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number303615-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: