Provider Demographics
NPI:1083438774
Name:NICELY, MIRANDA (FNP-C)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:NICELY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 620
Mailing Address - Street 2:
Mailing Address - City:WEST FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04992-0620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 CENTRE ST STE 200
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2550
Practice Address - Country:US
Practice Address - Phone:207-386-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP241405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily