Provider Demographics
NPI:1134619257
Name:SYRISTATIDES, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SYRISTATIDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SYRISTATIDES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SPECIAL TIMES RESPIT
Mailing Address - Street 1:174 DRAKE LN
Mailing Address - Street 2:
Mailing Address - City:LEDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07852-9688
Mailing Address - Country:US
Mailing Address - Phone:908-370-8289
Mailing Address - Fax:
Practice Address - Street 1:174 DRAKE LN
Practice Address - Street 2:
Practice Address - City:LEDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07852-9688
Practice Address - Country:US
Practice Address - Phone:908-370-8289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0450266244OtherRESPITE CARE LLC