Provider Demographics
NPI:1497257562
Name:HARRIS, NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HARRIS
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 1:203 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1946
Mailing Address - Country:US
Mailing Address - Phone:315-879-5178
Mailing Address - Fax:
Practice Address - Street 1:419 E MILLER ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1563
Practice Address - Country:US
Practice Address - Phone:315-690-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3209881164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse