Provider Demographics
NPI:1740768365
Name:RODRIGUE, NICHOLAS (PNP-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RODRIGUE
Suffix:
Gender:M
Credentials:PNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MOUNT TOM AVE
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-2350
Mailing Address - Country:US
Mailing Address - Phone:617-949-9110
Mailing Address - Fax:
Practice Address - Street 1:1049 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2114
Practice Address - Country:US
Practice Address - Phone:413-739-1100
Practice Address - Fax:413-735-1133
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2291141363LP0200X
CT7924363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics