Provider Demographics
NPI:1710540554
Name:GRAY-BROOKS, NICODEE SIMONE
Entity Type:Individual
Prefix:
First Name:NICODEE
Middle Name:SIMONE
Last Name:GRAY-BROOKS
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 1:29 ADAMSON AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-4601
Mailing Address - Country:US
Mailing Address - Phone:914-513-8684
Mailing Address - Fax:
Practice Address - Street 1:153 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2543
Practice Address - Country:US
Practice Address - Phone:914-668-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily