Provider Demographics
NPI:1598185894
Name:BERTI-MANSOUR, NICOLE A (NP)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:A
Last Name:BERTI-MANSOUR
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 1:9 MICHAEL CT
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2267
Mailing Address - Country:US
Mailing Address - Phone:516-858-6978
Mailing Address - Fax:
Practice Address - Street 1:9 MICHAEL CT
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-2267
Practice Address - Country:US
Practice Address - Phone:516-858-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306847363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health