Healthcare Provider Details

I. General information

NPI: 1336404870
Provider Name (Legal Business Name): NICOLE GELLER M.SED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 RIVERSIDE DR APT. 1E
NEW YORK NY
10025-6169
US

IV. Provider business mailing address

244 RIVERSIDE DRIVE APT. 1E
NEW YORK NY
10025
US

V. Phone/Fax

Practice location:
  • Phone: 646-295-6903
  • Fax:
Mailing address:
  • Phone: 646-295-6903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number616774051
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: