Provider Demographics
NPI:1093104861
Name:WILLETTE, NICKOLAS R (ABOC, NCLC, LDO)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:R
Last Name:WILLETTE
Suffix:
Gender:M
Credentials:ABOC, NCLC, LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02723-2719
Mailing Address - Country:US
Mailing Address - Phone:774-276-5703
Mailing Address - Fax:888-492-9389
Practice Address - Street 1:1502 LOCUST ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-2719
Practice Address - Country:US
Practice Address - Phone:774-276-5703
Practice Address - Fax:888-492-9389
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6426156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
46-1793649OtherTID