Provider Demographics
NPI:1770199341
Name:CARISSIMI, NICOLE KASSANDRA (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KASSANDRA
Last Name:CARISSIMI
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MINIUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6231
Mailing Address - Country:US
Mailing Address - Phone:267-639-5901
Mailing Address - Fax:
Practice Address - Street 1:255 S 17TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6231
Practice Address - Country:US
Practice Address - Phone:267-639-5901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-19
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022542363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health