Provider Demographics
NPI:1285610493
Name:NICKERSON, NANCY M (GNP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:M
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:GNP
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 284
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0284
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-5363
Practice Address - Street 1:655 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1543
Practice Address - Country:US
Practice Address - Phone:207-602-3571
Practice Address - Fax:207-602-3573
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER025597363LG0600X
MECNP81608363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME276700099Medicaid
NH30344302Medicaid
MENP1391Medicare ID - Type Unspecified
ME276700099Medicaid
NP1391Medicare PIN
NH30344302Medicaid