Provider Demographics
NPI:1780008201
Name:NICHOLAS, SHAMARA
Entity Type:Individual
Prefix:
First Name:SHAMARA
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6242 SILVER BIRCH DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-1056
Mailing Address - Country:US
Mailing Address - Phone:585-690-4887
Mailing Address - Fax:
Practice Address - Street 1:6242 SILVER BIRCH DRIVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-1056
Practice Address - Country:US
Practice Address - Phone:585-690-4887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY668937163W00000X
FL9373124163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse