Provider Demographics
NPI:1770001166
Name:CANDRILLI, NICOLE LAUREN (MS,LAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LAUREN
Last Name:CANDRILLI
Suffix:
Gender:F
Credentials:MS,LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3860
Mailing Address - Country:US
Mailing Address - Phone:646-872-1985
Mailing Address - Fax:
Practice Address - Street 1:4454 AUSTIN BLVD
Practice Address - Street 2:
Practice Address - City:ISLAND PARK
Practice Address - State:NY
Practice Address - Zip Code:11558-1621
Practice Address - Country:US
Practice Address - Phone:646-872-1985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006059171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist