Provider Demographics
NPI:1881997088
Name:NICKERSON, BERKLEY (NP)
Entity type:Individual
Prefix:MRS
First Name:BERKLEY
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BRADHURST AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2140
Mailing Address - Country:US
Mailing Address - Phone:914-493-7997
Mailing Address - Fax:914-594-4022
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-493-7997
Practice Address - Fax:914-594-4022
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18437363LF0000X
NYF339223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04059656Medicaid
CANP18437Medicaid
CAFX701ZMedicare PIN