Provider Demographics
NPI:1063773976
Name:GRIFFIN, NICOLE VERA (MSED)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:VERA
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 BEACH 81ST ST
Mailing Address - Street 2:APT 2F
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1902
Mailing Address - Country:US
Mailing Address - Phone:347-246-7307
Mailing Address - Fax:
Practice Address - Street 1:260 BEACH 81ST ST
Practice Address - Street 2:APT 2F
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1902
Practice Address - Country:US
Practice Address - Phone:347-246-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist