Provider Demographics
NPI:1508129230
Name:FISHER, NICOLE M
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:M
Last Name:FISHER
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 1:8 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-3201
Mailing Address - Country:US
Mailing Address - Phone:631-830-3330
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLZ
Practice Address - Street 2:SUITE 350
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3302
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:516-747-1833
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304077091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOtherSPECIALIST