Basic Information
| Provider Information | |||||||||
| NPI: | 1215557756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 DEANNA LN | ||||||||
| Address2: | |||||||||
| City: | WOLCOTT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067163143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035287409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 WILLARD AVE | ||||||||
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| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061112631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606666951 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2020 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3163 | CT | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.