MEDICARE: MARIE B NICOLAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1962763946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE B NICOLAS

Provider Business Mailing Address
First Line	:	2509 BROADWAY
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11106-3413
Country	:	US
Telephone Number	:	718-728-8476
Fax Number	:	718-204-7570

Provider Business Practice Location Address
First Line	:	2509 BROADWAY
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11106-3413
Country	:	US
Telephone Number	:	718-728-8476
Fax Number	:	718-204-7570

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2012
Last Update Date	:	08/28/2013

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Directions to “ MARIE B NICOLAS ” Practice Location

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