Provider Demographics
NPI:1992186712
Name:NICOLE HARRIS
Entity Type:Organization
Organization Name:NICOLE HARRIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PRACTICAL NURSE
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-945-0474
Mailing Address - Street 1:132 WILLOW AVENEUE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513
Mailing Address - Country:US
Mailing Address - Phone:315-945-0474
Mailing Address - Fax:
Practice Address - Street 1:132 WILLOW AVENUE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513
Practice Address - Country:US
Practice Address - Phone:315-945-0474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY691244271313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility