Provider Demographics
NPI:1558922997
Name:NICHOLAS, SAMANTHA JOSEPHINE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOSEPHINE
Last Name:NICHOLAS
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 1:1721 LAKES RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4332
Mailing Address - Country:US
Mailing Address - Phone:845-591-8745
Mailing Address - Fax:
Practice Address - Street 1:75 CRYSTAL RUN RD STE 201
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7010
Practice Address - Country:US
Practice Address - Phone:845-692-4391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist