Provider Demographics
NPI:1407155542
Name:EDGAR, NICOLE B
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:B
Last Name:EDGAR
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 1:98 BEECHWOOD PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3064
Mailing Address - Country:US
Mailing Address - Phone:646-483-9009
Mailing Address - Fax:
Practice Address - Street 1:98 BEECHWOOD PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3064
Practice Address - Country:US
Practice Address - Phone:646-483-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017576-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist