Provider Demographics
NPI:1396704060
Name:NICKELL, KAREN MAY (MD)
Entity type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:MAY
Last Name:NICKELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MAY
Other - Last Name:MANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:221 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NY
Mailing Address - Zip Code:14522-1127
Mailing Address - Country:US
Mailing Address - Phone:315-502-4085
Mailing Address - Fax:315-502-4086
Practice Address - Street 1:221 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NY
Practice Address - Zip Code:14522-1127
Practice Address - Country:US
Practice Address - Phone:315-502-4085
Practice Address - Fax:315-502-4086
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01914272Medicaid
NYP010212521OtherBLUE CHOICE
NY1142OtherBLUE CROSS/BLUE SHIELD
NYMDE045OtherPREFERRED CARE
NYG87117Medicare UPIN
NYMDE045OtherPREFERRED CARE