Provider Demographics
NPI:1912569070
Name:LEROUGE, NICOLE (RN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEROUGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1663 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1259
Mailing Address - Country:US
Mailing Address - Phone:718-998-0200
Mailing Address - Fax:
Practice Address - Street 1:4 CAMP AVE
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-1404
Practice Address - Country:US
Practice Address - Phone:607-865-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY424739163WS0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty