Provider Demographics
NPI:1295070431
Name:FRIED, NICOLE (MED)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FRIED
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FAIRFIELD WAY
Mailing Address - Street 2:APT 12
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3424
Mailing Address - Country:US
Mailing Address - Phone:516-647-2254
Mailing Address - Fax:
Practice Address - Street 1:125 E BETHPAGE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4228
Practice Address - Country:US
Practice Address - Phone:631-567-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1061898174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist