Provider Demographics
NPI:1164900346
Name:FENTON, NICOLE LYNETTE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNETTE
Last Name:FENTON
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 1:135 CORSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2933
Mailing Address - Country:US
Mailing Address - Phone:718-450-4727
Mailing Address - Fax:
Practice Address - Street 1:135 CORSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2933
Practice Address - Country:US
Practice Address - Phone:718-450-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator