Provider Demographics
NPI:1659634723
Name:NICKOLAI, LAURA (COMS; CVRT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:NICKOLAI
Suffix:
Gender:F
Credentials:COMS; CVRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8017A MARLIN DR
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8926
Mailing Address - Country:US
Mailing Address - Phone:315-699-6133
Mailing Address - Fax:
Practice Address - Street 1:8017A MARLIN DR
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-8926
Practice Address - Country:US
Practice Address - Phone:315-699-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3299174400000X
NY2219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist