Provider Demographics
NPI:1427454545
Name:FORREST, NICOLE GEISHA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:GEISHA
Last Name:FORREST
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 1:780 THOMAS S BOYLAND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-4433
Mailing Address - Country:US
Mailing Address - Phone:347-277-4944
Mailing Address - Fax:
Practice Address - Street 1:780 THOMAS S BOYLAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-4433
Practice Address - Country:US
Practice Address - Phone:347-277-4944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1886966174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist