Provider Demographics
NPI:1003154543
Name:ANDRUS, NICOLE (DAOM, LAC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:ANDRUS
Suffix:
Gender:F
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 SWAN ST UNIT 103
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-2624
Mailing Address - Country:US
Mailing Address - Phone:614-218-1363
Mailing Address - Fax:
Practice Address - Street 1:135 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-2416
Practice Address - Country:US
Practice Address - Phone:716-218-9338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006927171100000X
OH65.000301171100000X
NJ25MZ00112000171100000X
IL198.001041171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist