Provider Demographics
NPI:1043374986
Name:KULISEK, NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:KULISEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3000 VALLEY FORGE CIR APT 1543
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1150
Mailing Address - Country:US
Mailing Address - Phone:617-251-4803
Mailing Address - Fax:
Practice Address - Street 1:500 ARCOLA RD
Practice Address - Street 2:
Practice Address - City:COLLEGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19426-3982
Practice Address - Country:US
Practice Address - Phone:646-942-6148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249629208000000X
NY2486292080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03437845Medicaid