Basic Information
| Provider Information | |||||||||
| NPI: | 1366848038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOLAS | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1353 BERKLEY ST | ||||||||
| Address2: | |||||||||
| City: | NORTH BALDWIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115101304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162242400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3003 NEW HYDE PARK RD STE 401 | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162242400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2014 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F339034-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.