Basic Information
| Provider Information | |||||||||
| NPI: | 1518540905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVERETT | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 JOSEPH CIR | ||||||||
| Address2: | |||||||||
| City: | HIGGANUM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064414059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607073574 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 WILLARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEWINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061112631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606666951 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2021 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3197 | CT | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.