Provider Demographics
NPI:1831489780
Name:SAMUEL, NICHOLE MONIQUE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:MONIQUE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY DEPT. OF MANAGED CARE ROOM 2B 230
Mailing Address - Street 2:WOODHULL MEDICAL & MENTAL HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206
Mailing Address - Country:US
Mailing Address - Phone:718-630-8000
Mailing Address - Fax:718-630-3122
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:WOODHULL MENTAL & MENTAL HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-630-8000
Practice Address - Fax:718-630-3122
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001419176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife