Provider Demographics
NPI:1932139763
Name:GARRAWAY, NICHOLA ALTHEA (OPTITIAN)
Entity Type:Individual
Prefix:
First Name:NICHOLA
Middle Name:ALTHEA
Last Name:GARRAWAY
Suffix:
Gender:F
Credentials:OPTITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11502 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-1902
Mailing Address - Country:US
Mailing Address - Phone:718-835-8000
Mailing Address - Fax:
Practice Address - Street 1:11502 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1902
Practice Address - Country:US
Practice Address - Phone:718-835-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008313-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician