Provider Demographics
NPI:1700238623
Name:NICHOLAS, COURTNEY (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 N OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1723 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2687
Practice Address - Country:US
Practice Address - Phone:631-758-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-02
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307763363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health