Provider Demographics
NPI:1013776137
Name:TYCHOSTUP, NICOLE RAY (RN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAY
Last Name:TYCHOSTUP
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:107 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12188-2025
Mailing Address - Country:US
Mailing Address - Phone:228-297-6071
Mailing Address - Fax:
Practice Address - Street 1:107 4TH ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:NY
Practice Address - Zip Code:12188-2025
Practice Address - Country:US
Practice Address - Phone:228-297-6071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY700535163WC0400X, 163WP1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP1700XNursing Service ProvidersRegistered NursePerinatal
No163WC0400XNursing Service ProvidersRegistered NurseCase Management