Provider Demographics
NPI:1205029097
Name:NIEDZWIEDZ, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NIEDZWIEDZ
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 1:3725 N BUFFALO ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1853
Mailing Address - Country:US
Mailing Address - Phone:716-662-2300
Mailing Address - Fax:716-662-2057
Practice Address - Street 1:3725 N BUFFALO ST
Practice Address - Street 2:SUITE A
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1853
Practice Address - Country:US
Practice Address - Phone:716-662-2300
Practice Address - Fax:716-662-2057
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3819232080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine