Provider Demographics
NPI:1174386650
Name:SMYTH, NICOLE A
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:SMYTH
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:580 WOODROW RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1230
Mailing Address - Country:US
Mailing Address - Phone:917-369-0609
Mailing Address - Fax:
Practice Address - Street 1:580 WOODROW RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-1230
Practice Address - Country:US
Practice Address - Phone:917-369-0609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency