Provider Demographics
NPI:1114507746
Name:FULLONE, NICHOLAS WILLIAM
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:WILLIAM
Last Name:FULLONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 ACKERLY LN
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4549
Mailing Address - Country:US
Mailing Address - Phone:631-375-2196
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4213
Practice Address - Country:US
Practice Address - Phone:800-233-5744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY812388163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse