Provider Demographics
NPI:1134394323
Name:BROWN, NICOLE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16318 JAMAICA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4901
Mailing Address - Country:US
Mailing Address - Phone:718-450-9242
Mailing Address - Fax:646-905-0404
Practice Address - Street 1:16318 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4919
Practice Address - Country:US
Practice Address - Phone:718-450-9242
Practice Address - Fax:646-905-0404
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY270554208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid