Provider Demographics
NPI:1366848038
Name:NICOLAS, JACQUELINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 BERKLEY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1304
Mailing Address - Country:US
Mailing Address - Phone:516-224-2400
Mailing Address - Fax:
Practice Address - Street 1:3003 NEW HYDE PARK RD STE 401
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1214
Practice Address - Country:US
Practice Address - Phone:516-224-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-07
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339034-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily