Provider Demographics
NPI:1467636431
Name:NICHOLS, BRIENNE
Entity Type:Individual
Prefix:MISS
First Name:BRIENNE
Middle Name:
Last Name:NICHOLS
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 1:1625 BROADWAY STREET
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14212
Mailing Address - Country:US
Mailing Address - Phone:716-894-2443
Mailing Address - Fax:716-892-6355
Practice Address - Street 1:1625 BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14212
Practice Address - Country:US
Practice Address - Phone:716-894-2443
Practice Address - Fax:716-892-6355
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00714076Medicaid