Provider Demographics
NPI:1689834525
Name:ROCKOWITZ, NICHOLE LYNN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:LYNN
Last Name:ROCKOWITZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57190 ROUTE 25
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-4750
Mailing Address - Country:US
Mailing Address - Phone:631-765-3620
Mailing Address - Fax:
Practice Address - Street 1:57190 ROUTE 25
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971
Practice Address - Country:US
Practice Address - Phone:631-765-3620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309222363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1689834525Medicaid