Basic Information
| Provider Information | |||||||||
| NPI: | 1427371962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSHER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
| FaxNumber: | 6078731244 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 IVY ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149051646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077354633 | ||||||||
| FaxNumber: | 6077354628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2010 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F336204-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 336204 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 03196458 | 05 | NY | MEDICAID |