Provider Demographics
NPI:1700344389
Name:NICHOLAS, LAURA JEANNE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEANNE
Last Name:NICHOLAS
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 1:25 COUNTY ROUTE 51
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:NY
Mailing Address - Zip Code:13697-3144
Mailing Address - Country:US
Mailing Address - Phone:315-328-5911
Mailing Address - Fax:
Practice Address - Street 1:31 6TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1246
Practice Address - Country:US
Practice Address - Phone:518-651-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist