Provider Demographics
NPI:1649203555
Name:NICHOLS, MARY ELLEN (PNP)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:CAPECE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-368-4012
Practice Address - Fax:585-368-4019
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381231363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02573513Medicaid