Provider Demographics
NPI:1396788139
Name:NICKERSON, KARYN (CNM)
Entity type:Individual
Prefix:MRS
First Name:KARYN
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 ROSAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:NY
Mailing Address - Zip Code:14871-9528
Mailing Address - Country:US
Mailing Address - Phone:607-732-2206
Mailing Address - Fax:
Practice Address - Street 1:1005 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-1007
Practice Address - Country:US
Practice Address - Phone:607-734-3968
Practice Address - Fax:607-734-4554
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000800176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01902161Medicare ID - Type Unspecified
NYS88810Medicare UPIN
NYBB6748Medicare ID - Type Unspecified