Provider Demographics
NPI:1295833598
Name:ROUHANA, NICOLE A (FNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:ROUHANA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:ROUHANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD; CNM
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-240-2885
Mailing Address - Fax:607-240-2886
Practice Address - Street 1:4417 VESTAL PKWY E
Practice Address - Street 2:BREAST CENTER
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3556
Practice Address - Country:US
Practice Address - Phone:607-240-2885
Practice Address - Fax:607-240-2886
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000176367A00000X
NY333072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD1496Medicare PIN
NYS22001Medicare UPIN