Healthcare Provider Details

I. General information

NPI: 1003670456
Provider Name (Legal Business Name): NICOLE BERMISA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

9010 32ND AVE APT 504
EAST ELMHURST NY
11369-2299
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-7566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number353564
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: