Provider Demographics
NPI:1760797229
Name:NICKERSON, RENEE (NP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3942 ROCKWELL RD
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-9640
Mailing Address - Country:US
Mailing Address - Phone:315-673-2802
Mailing Address - Fax:
Practice Address - Street 1:4567 CROSSROADS PARK DR
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3589
Practice Address - Country:US
Practice Address - Phone:315-883-1631
Practice Address - Fax:315-883-1688
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY402840363LP0808X
NY335994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health