Provider Demographics
NPI:1619521218
Name:YASSINE, NICOLE MARIE (LOM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:YASSINE
Suffix:
Gender:F
Credentials:LOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 RIDGE AVE # C-2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-1538
Mailing Address - Country:US
Mailing Address - Phone:860-995-5987
Mailing Address - Fax:
Practice Address - Street 1:2308 GRAYS FERRY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1177
Practice Address - Country:US
Practice Address - Phone:215-772-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOM000240171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist