Provider Demographics
NPI:1649731266
Name:LIGHTHOUSE, NICOLE CATHERINE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CATHERINE
Last Name:LIGHTHOUSE
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 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-1900
Mailing Address - Fax:585-922-1002
Practice Address - Street 1:224 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-4000
Practice Address - Country:US
Practice Address - Phone:585-922-7770
Practice Address - Fax:585-922-7775
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3225932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry