Provider Demographics
NPI:1104188200
Name:IACOVELLI, NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:IACOVELLI
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-1944
Mailing Address - Country:US
Mailing Address - Phone:914-447-8467
Mailing Address - Fax:
Practice Address - Street 1:20 CEDAR ST
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-5247
Practice Address - Country:US
Practice Address - Phone:914-576-3168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist