1104308386 NPI number — MRS. RENEE ADRIANA NICHOLS FNP-BC

Table of content: JENNIFER YARELI ROSAS GOMEZ (NPI 1891344859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104308386 NPI number — MRS. RENEE ADRIANA NICHOLS FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
RENEE
Provider Middle Name:
ADRIANA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
RENEE
Provider Other Middle Name:
ADRIANA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104308386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19116 115TH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT ALBANS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11412-2708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-914-5335
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7960 METROPOLITAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLE VILLAGE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11379-2931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-326-4910
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  F343442-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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