Provider Demographics
NPI:1164852943
Name:MASCOLI, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MASCOLI
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 1:3521 205TH ST
Mailing Address - Street 2:APT 314
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1222
Mailing Address - Country:US
Mailing Address - Phone:516-233-6325
Mailing Address - Fax:
Practice Address - Street 1:3521 205TH ST
Practice Address - Street 2:APT 314
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1222
Practice Address - Country:US
Practice Address - Phone:516-233-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1148565174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist