Provider Demographics
NPI:1639546336
Name:SANDBERG, NICOLE A (MSN-PMHNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:MSN-PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NICOLLS RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-638-1575
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-638-1575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY660968163WP0808X
NY401946363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health