Provider Demographics
NPI:1518540905
Name:EVERETT, NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:EVERETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 JOSEPH CIR
Mailing Address - Street 2:
Mailing Address - City:HIGGANUM
Mailing Address - State:CT
Mailing Address - Zip Code:06441-4059
Mailing Address - Country:US
Mailing Address - Phone:860-707-3574
Mailing Address - Fax:
Practice Address - Street 1:555 WILLARD AVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2631
Practice Address - Country:US
Practice Address - Phone:860-666-6951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist