Provider Demographics
NPI:1770156622
Name:SMITH ALLEN, NICOLE ANTOINETTE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANTOINETTE
Last Name:SMITH ALLEN
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 1:629 WELLWOOD AVE APT 5A
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-2041
Mailing Address - Country:US
Mailing Address - Phone:631-520-3040
Mailing Address - Fax:
Practice Address - Street 1:629 WELLWOOD AVE APT 5A
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2041
Practice Address - Country:US
Practice Address - Phone:631-520-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00512729251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health