Provider Demographics
NPI:1124585682
Name:RAINEY, NICOLE LATONYA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LATONYA
Last Name:RAINEY
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 1:1204 JAQUES AVE
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-3928
Mailing Address - Country:US
Mailing Address - Phone:908-405-3411
Mailing Address - Fax:
Practice Address - Street 1:1204 JAQUES AVE
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-3928
Practice Address - Country:US
Practice Address - Phone:908-405-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32WG06066900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist