Basic Information
Provider Information | |||||||||
NPI: | 1073840906 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NICOLL | ||||||||
FirstName: | LESLIE | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 389 CONGRESS ST | ||||||||
Address2: | ROOM 307 | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041013566 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078748784 | ||||||||
FaxNumber: | 2078748913 | ||||||||
Practice Location | |||||||||
Address1: | 103 INDIA ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | ME | ||||||||
PostalCode: | 041014211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078748446 | ||||||||
FaxNumber: | 2077568087 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2009 | ||||||||
LastUpdateDate: | 11/13/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R023516 | ME | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | R023516 | 01 | ME | RN LICENSE | OTHER |