Provider Demographics
NPI:1710329826
Name:NICHOLAS, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 SANDRA PL
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5306
Mailing Address - Country:US
Mailing Address - Phone:716-870-4732
Mailing Address - Fax:
Practice Address - Street 1:136 HELEN AVE
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219-1647
Practice Address - Country:US
Practice Address - Phone:716-870-4732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist