Provider Demographics
NPI:1790789352
Name:NIELSEN, NOELLE
Entity Type:Individual
Prefix:
First Name:NOELLE
Middle Name:
Last Name:NIELSEN
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 1:45 HUDSON AVE
Mailing Address - Street 2:PO BOX 144
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4313
Mailing Address - Country:US
Mailing Address - Phone:518-793-4477
Mailing Address - Fax:
Practice Address - Street 1:45 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4313
Practice Address - Country:US
Practice Address - Phone:518-793-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146970207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426007601OtherFIDELIS
NY78E642OtherBLUE CROSS
NY15124OtherMVP
NY000416199001OtherBLUE SHIELD
NY00912010Medicaid
NY10001475OtherCDPHP
NYE15647Medicare UPIN
NY000416199001OtherBLUE SHIELD