Provider Demographics
NPI:1104308386
Name:NICHOLS, RENEE ADRIANA (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:ADRIANA
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MISS
Other - First Name:RENEE
Other - Middle Name:ADRIANA
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19116 115TH RD
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2708
Mailing Address - Country:US
Mailing Address - Phone:954-914-5335
Mailing Address - Fax:
Practice Address - Street 1:7960 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-2931
Practice Address - Country:US
Practice Address - Phone:718-326-4910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF343442-1363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily