Provider Demographics
NPI:1710077821
Name:NICOSIA, THERESA JEANNE (RN MS FNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:JEANNE
Last Name:NICOSIA
Suffix:
Gender:F
Credentials:RN MS FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PARK VIEW LN
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1854
Mailing Address - Country:US
Mailing Address - Phone:631-467-8229
Mailing Address - Fax:
Practice Address - Street 1:6 PARK VIEW LN
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1854
Practice Address - Country:US
Practice Address - Phone:631-467-8229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334231-1363LF0000X
NYF334231363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02703515Medicaid
NY02703515Medicaid
NY02703515Medicaid