Provider Demographics
NPI:1386616977
Name:NICKERSON, CHEVONNE MARIE (FNP)
Entity type:Individual
Prefix:MS
First Name:CHEVONNE
Middle Name:MARIE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:130 CENTERWAY
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830
Practice Address - Country:US
Practice Address - Phone:607-973-8000
Practice Address - Fax:607-973-8161
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331493207Q00000X
NYF331493-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY500019277OtherRR MEDICARE PIN
NY01731906Medicaid
NYCC8362OtherRR MEDICARE GROUP
NYCC2035Medicare ID - Type Unspecified
NY500019277OtherRR MEDICARE PIN