Healthcare Provider Details

I. General information

NPI: 1548523905
Provider Name (Legal Business Name): MS. HEIDI ANN NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 JEANNE MARIE GDNS APT K
NANUET NY
10954-1952
US

IV. Provider business mailing address

14 JEANNE MARIE GDNS
NANUET NY
10954-1923
US

V. Phone/Fax

Practice location:
  • Phone: 845-729-1394
  • Fax:
Mailing address:
  • Phone: 845-729-1394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number618828
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: