Provider Demographics
NPI:1194482331
Name:NORTHRUP, NICOLE ALANA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALANA
Last Name:NORTHRUP
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 1:35 WILLOWICK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-8904
Mailing Address - Country:US
Mailing Address - Phone:585-245-3422
Mailing Address - Fax:
Practice Address - Street 1:665 AYRAULT RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3000
Practice Address - Country:US
Practice Address - Phone:585-421-2067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY715382163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool