Provider Demographics
NPI:1619351343
Name:BRINN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BRINN
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 1:44 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053-8514
Mailing Address - Country:US
Mailing Address - Phone:607-844-8273
Mailing Address - Fax:
Practice Address - Street 1:44 NORTH ST
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053-8514
Practice Address - Country:US
Practice Address - Phone:607-844-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214120183500000X
NY066717183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VABT6812350OtherDEA