Provider Demographics
NPI:1194561464
Name:CHRISTENSEN, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CHRISTENSEN
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 1:185 PORTERFIELD PL
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3142
Mailing Address - Country:US
Mailing Address - Phone:516-584-2007
Mailing Address - Fax:
Practice Address - Street 1:185 PORTERFIELD PL
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3142
Practice Address - Country:US
Practice Address - Phone:516-584-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker