Healthcare Provider Details

I. General information

NPI: 1740062025
Provider Name (Legal Business Name): NICOLE ODINSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 EMERSON ST
WOODMERE NY
11598-2836
US

IV. Provider business mailing address

707 EMERSON ST
WOODMERE NY
11598-2836
US

V. Phone/Fax

Practice location:
  • Phone: 917-968-6427
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00992900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: