Provider Demographics
NPI:1558619734
Name:PETHIC, NICOLE (MSE)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:PETHIC
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ROCK CITY RD
Mailing Address - Street 2:
Mailing Address - City:RED HOOK
Mailing Address - State:NY
Mailing Address - Zip Code:12571-2414
Mailing Address - Country:US
Mailing Address - Phone:845-758-8805
Mailing Address - Fax:
Practice Address - Street 1:268 W SAUGERTIES RD
Practice Address - Street 2:
Practice Address - City:SAUGERTIES
Practice Address - State:NY
Practice Address - Zip Code:12477-3142
Practice Address - Country:US
Practice Address - Phone:845-247-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY638254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist