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General NPI Number Information
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NPI Number | 1558619734
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Entity Type | Individual
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Provider Name | NICOLE PETHIC MSE
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Gender | Female
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Dates
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Enumeration Date | 08/20/2012
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Last Update Date | 08/20/2012
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Provider Practice Location Address
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Address Line | 268 W SAUGERTIES RD
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City | SAUGERTIES
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State | NY
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Zip | 12477-3142
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Country | US
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Telephone | 845-247-8777
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Fax |
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Provider Business Mailing Address
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Address Line | 31 ROCK CITY RD
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City | RED HOOK
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State | NY
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Zip | 12571-2414
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Country | US
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Telephone | 845-758-8805
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 638254
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License Number State | NY
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