Provider Demographics
NPI:1558713180
Name:MCNICHOLAS, MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MCNICHOLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1899 ROUTE 88
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3124
Mailing Address - Country:US
Mailing Address - Phone:732-840-8177
Mailing Address - Fax:
Practice Address - Street 1:1899 ROUTE 88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3124
Practice Address - Country:US
Practice Address - Phone:732-840-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00651000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily