Healthcare Provider Details

I. General information

NPI: 1124697305
Provider Name (Legal Business Name): NICOLE J WALSH PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 07/07/2023
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E RIVER RD
ROCHESTER NY
14623-1212
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 278984
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-2808
  • Fax: 585-275-3683
Mailing address:
  • Phone: 585-275-2808
  • Fax: 585-275-3683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number383255
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF383255
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: