Provider Demographics
NPI:1609213917
Name:VANDERMAY, NICOLE ASHLEY (BA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ASHLEY
Last Name:VANDERMAY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01905-2229
Mailing Address - Country:US
Mailing Address - Phone:781-595-7348
Mailing Address - Fax:
Practice Address - Street 1:9 WOODWARD ST
Practice Address - Street 2:APT. 3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127
Practice Address - Country:US
Practice Address - Phone:215-850-9694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59938755390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program