Provider Demographics
NPI:1093148637
Name:SCALA, NICOLE CHRISTIN
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:CHRISTIN
Last Name:SCALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BRAGG DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2304
Mailing Address - Country:US
Mailing Address - Phone:631-220-6755
Mailing Address - Fax:
Practice Address - Street 1:18 BRAGG DR
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2304
Practice Address - Country:US
Practice Address - Phone:631-220-6755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431654101174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator