Provider Demographics
NPI:1811650302
Name:MOSS, NICOLE DANIELLE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DANIELLE
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:DANIELLE
Other - Last Name:LISANDRELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4445 MIDDLE SETTLEMENT RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-5319
Mailing Address - Country:US
Mailing Address - Phone:315-790-3634
Mailing Address - Fax:
Practice Address - Street 1:4445 MIDDLE SETTLEMENT RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-5319
Practice Address - Country:US
Practice Address - Phone:315-790-3634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist