Provider Demographics
NPI:1457683682
Name:NICHOLS, CORALYN ANTONETTE (LPN)
Entity Type:Individual
Prefix:MS
First Name:CORALYN
Middle Name:ANTONETTE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10211 186TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-3107
Mailing Address - Country:US
Mailing Address - Phone:646-387-6840
Mailing Address - Fax:
Practice Address - Street 1:16937 144TH RD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5929
Practice Address - Country:US
Practice Address - Phone:718-978-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298893164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse