Provider Demographics
NPI:1215337894
Name:NICOLAS, ROSELE
Entity type:Individual
Prefix:
First Name:ROSELE
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 HENDRICKSON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5041
Mailing Address - Country:US
Mailing Address - Phone:718-508-2047
Mailing Address - Fax:
Practice Address - Street 1:2150 HENDRICKSON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5041
Practice Address - Country:US
Practice Address - Phone:718-508-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338721363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily