Provider Demographics
NPI:1407212319
Name:NICOLAS, DAPHNEY
Entity Type:Individual
Prefix:
First Name:DAPHNEY
Middle Name:
Last Name:NICOLAS
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 1:271 W 146TH ST APT 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-3756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 WEST 146 STREET APT #9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039
Practice Address - Country:US
Practice Address - Phone:347-446-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No171M00000XOther Service ProvidersCase Manager/Care Coordinator