Basic Information
| Provider Information | |||||||||
| NPI: | 1598059586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLAPIANO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LYNN GERGEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GERGEN | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 85 SOUTH WEST STREET | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 4038 WEST RD | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130451842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077583008 | ||||||||
| FaxNumber: | 6077589515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301107537 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 4301107537 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | LP02344 | RI | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | LP02344 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04807916 | 05 | NY | MEDICAID |