Provider Demographics
NPI:1689823213
Name:GRECO, NICOLE D (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:GRECO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 TOWN BROOKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-6630
Mailing Address - Country:US
Mailing Address - Phone:516-425-8583
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-647-6459
Practice Address - Fax:860-533-2975
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002135363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant