Provider Demographics
NPI:1255379103
Name:CRETELLA NICKOU, KARI (RN, MSN,CS)
Entity type:Individual
Prefix:MS
First Name:KARI
Middle Name:
Last Name:CRETELLA NICKOU
Suffix:
Gender:F
Credentials:RN, MSN,CS
Other - Prefix:
Other - First Name:KARI
Other - Middle Name:
Other - Last Name:CRETELLA NICKOU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25 BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01951-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-2619
Practice Address - Country:US
Practice Address - Phone:508-843-1801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN169922364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110110173AMedicaid
MA110110173AMedicaid