Provider Demographics
NPI:1063400547
Name:NICKLES, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:NICKLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 EISENHOWER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1401
Mailing Address - Country:US
Mailing Address - Phone:201-843-2800
Mailing Address - Fax:973-939-0273
Practice Address - Street 1:80 EISENHOWER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1401
Practice Address - Country:US
Practice Address - Phone:201-843-2800
Practice Address - Fax:973-939-0273
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03792500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2807666OtherAETNA HMO #
NJ39F312OtherEMPIRE BCBS #
NJ160055692OtherRAILROAD MCR #
NJ1K4890OtherHEALTHNET #
NJP2631203OtherOXFORD #
NJ0105583000OtherAMERIHEALTH #
NJ4252756OtherAETNA PPO #
NJ4252756OtherAETNA PPO #
NJ160055692OtherRAILROAD MCR #