Provider Demographics
NPI:1730318189
Name:FIELDS, NICHOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:FIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:MARIE
Other - Last Name:BOECKMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92 7TH AVE
Mailing Address - Street 2:APT. 6
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3650
Mailing Address - Country:US
Mailing Address - Phone:618-830-4623
Mailing Address - Fax:
Practice Address - Street 1:92 7TH AVE
Practice Address - Street 2:APT. 6
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3650
Practice Address - Country:US
Practice Address - Phone:618-830-4623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010878235Z00000X
NY025348235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist