Provider Demographics
NPI:1568803369
Name:DORNICIK, NICOLE ELIZABETH (AUD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:DORNICIK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 WHITE PLAINS RD
Mailing Address - Street 2:SUITE 560
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5113
Mailing Address - Country:US
Mailing Address - Phone:631-727-8050
Mailing Address - Fax:
Practice Address - Street 1:292 SHADE TREE LN
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-5020
Practice Address - Country:US
Practice Address - Phone:631-727-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002488-1231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400091836OtherMEDICARE PARTICIPATION NUMBER (PTAN #)