Healthcare Provider Details

I. General information

NPI: 1083436612
Provider Name (Legal Business Name): NICOLE SRISKANDA CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 BARD AVE
STATEN ISLAND NY
10310-1609
US

IV. Provider business mailing address

1935 UNION VALLEY RD APPT D
HEWITT NJ
07421-3031
US

V. Phone/Fax

Practice location:
  • Phone: 347-644-4896
  • Fax:
Mailing address:
  • Phone: 347-644-4896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number256644209
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: