Basic Information
| Provider Information | |||||||||
| NPI: | 1568503951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICOLICH | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 RAILROAD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHELLE PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076624101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012260700 | ||||||||
| FaxNumber: | 2018433012 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 GOFFLE RD | ||||||||
| Address2: | |||||||||
| City: | WYCKOFF | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074812937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8447770910 | ||||||||
| FaxNumber: | 2015600712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 5342 | NJ | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 10663040 | 01 | NJ | CAQH PROVIDER ID | OTHER |