Provider Demographics
NPI:1780815480
Name:BEAUBRUN, NICOLE LOUIS (NP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LOUIS
Last Name:BEAUBRUN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LOUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1211 HOWELLS RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1945
Mailing Address - Country:US
Mailing Address - Phone:631-586-3501
Mailing Address - Fax:
Practice Address - Street 1:1211 HOWELLS RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1945
Practice Address - Country:US
Practice Address - Phone:631-586-3501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305199363LP0808X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health