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General NPI Number Information
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NPI Number | 1578974630
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Entity Type | Individual
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Provider Name | NICOLE INNACE
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Gender | Female
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Dates
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Enumeration Date | 05/12/2014
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Last Update Date | 04/10/2015
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Provider Practice Location Address
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Address Line | 45 TIMBER RIDGE DR
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City | HOLBROOK
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State | NY
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Zip | 11741-4142
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Country | US
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Telephone | 631-472-8162
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Fax |
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Provider Business Mailing Address
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Address Line | 32 KENWOOD DR
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City | BOHEMIA
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State | NY
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Zip | 11716-1314
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Country | US
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Telephone | 631-472-8162
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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 | 353185091
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 415945101
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 800217131
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License Number State | NY
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