Provider Demographics
NPI:1316336704
Name:IZYDORCZAK, NIKOLINA (RN)
Entity type:Individual
Prefix:
First Name:NIKOLINA
Middle Name:
Last Name:IZYDORCZAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 BROADWAY STREET
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-1120
Mailing Address - Country:US
Mailing Address - Phone:716-225-0067
Mailing Address - Fax:
Practice Address - Street 1:3851 BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-1120
Practice Address - Country:US
Practice Address - Phone:716-225-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY800740-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse