Provider Demographics
NPI:1609388206
Name:LEIB, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:LEIB
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 1:7 SCHUMACHER POND RD
Mailing Address - Street 2:
Mailing Address - City:BARRYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12719-5303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 SCHUMACHER POND RD
Practice Address - Street 2:
Practice Address - City:BARRYVILLE
Practice Address - State:NY
Practice Address - Zip Code:12719-5303
Practice Address - Country:US
Practice Address - Phone:845-798-9825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-04
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY318542164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse