1861625790 NPI number — NICOLE LADD CPNP

Table of content: NICOLE LADD CPNP (NPI 1861625790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861625790 NPI number — NICOLE LADD CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADD
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861625790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 REASEARCH WAY
Provider Second Line Business Mailing Address:
STONY BROOK CHILDRENS SERVICES, UFPC
Provider Business Mailing Address City Name:
EAST SETAUKET
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-675-2125
Provider Business Mailing Address Fax Number:
631-675-2624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SAYVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11782-2540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-563-8190
Provider Business Practice Location Address Fax Number:
631-563-8194
Provider Enumeration Date:
08/26/2009

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: 163W00000X , with the licence number:  542820 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 381989 , 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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