Provider Demographics
NPI:1346320074
Name:SHIPP, NICOLE C (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:SHIPP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 WILDERNESS DR.
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-5824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:331 MAINE ST., SUITE 1
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3359
Practice Address - Country:US
Practice Address - Phone:207-725-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT787152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME337660099Medicaid
ME0310380001Medicare NSC
MEMM8244Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID
ME337660099Medicaid