Provider Demographics
NPI:1205919578
Name:NICKERSON, CHERYL MARIE (GNP)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:MARIE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:MARIE
Other - Last Name:FONAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:GNP-BC
Mailing Address - Street 1:150 PRATTSBURG RD.
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:NY
Mailing Address - Zip Code:14512
Mailing Address - Country:US
Mailing Address - Phone:585-943-1538
Mailing Address - Fax:
Practice Address - Street 1:7009 RUMSEY RD EXTENSION
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810
Practice Address - Country:US
Practice Address - Phone:607-661-9114
Practice Address - Fax:607-664-1020
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340488-1363LG0600X
NY340488363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02829629Medicaid