Provider Demographics
NPI:1336556828
Name:NICHOLAS, SHIRLEY MAY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MAY
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHIRLEY
Other - Middle Name:MAY
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ANP
Mailing Address - Street 1:820 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3102
Mailing Address - Country:US
Mailing Address - Phone:718-693-6795
Mailing Address - Fax:
Practice Address - Street 1:820 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3102
Practice Address - Country:US
Practice Address - Phone:718-693-6795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306681363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health