Provider Demographics
NPI:1790396919
Name:PELAN, NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PELAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3886 KEILY DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-2004
Mailing Address - Country:US
Mailing Address - Phone:516-729-8503
Mailing Address - Fax:
Practice Address - Street 1:1000 NORTHERN BLVD STE 360
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5312
Practice Address - Country:US
Practice Address - Phone:516-829-6660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344115363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily