Provider Demographics
NPI:1104142520
Name:OLENG, NICOLETTE A (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLETTE
Middle Name:A
Last Name:OLENG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLETTE
Other - Middle Name:ATIENO
Other - Last Name:OLENG'
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 ALBANY ST
Practice Address - Street 2:SHAPIRO 5, SUITE B
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2526
Practice Address - Country:US
Practice Address - Phone:617-414-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268289207R00000X
MA256338207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400114157Medicare PIN