Provider Demographics
NPI:1801076070
Name:ANSANELLI, NICHOLAS ANTHONY (RPH)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ANTHONY
Last Name:ANSANELLI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WESTMORELAND PL
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11363-1133
Mailing Address - Country:US
Mailing Address - Phone:718-423-2465
Mailing Address - Fax:
Practice Address - Street 1:14 SHORE RD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050
Practice Address - Country:US
Practice Address - Phone:516-883-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist