Provider Demographics
NPI:1598548760
Name:DEYETTE, NICOLE ALISON (FNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALISON
Last Name:DEYETTE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ALISON
Other - Last Name:NISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:585 NEW LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-5701
Mailing Address - Country:US
Mailing Address - Phone:518-783-1472
Mailing Address - Fax:
Practice Address - Street 1:585 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-5701
Practice Address - Country:US
Practice Address - Phone:518-783-1472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF351981363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily