Basic Information
| Provider Information | |||||||||
| NPI: | 1396832077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICOLL | ||||||||
| FirstName: | ANCA | ||||||||
| MiddleName: | MIOARA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419 | ||||||||
| Address2: | WOB | ||||||||
| City: | WEST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070520419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737368067 | ||||||||
| FaxNumber: | 9737368067 | ||||||||
| Practice Location | |||||||||
| Address1: | GREYSTONE PARK PSYCHIATRY HOSPITAL | ||||||||
| Address2: | |||||||||
| City: | GREYSTONE PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735381800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MA32057 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00739648 | 05 | NY | MEDICAID |