Provider Demographics
NPI:1427804863
Name:KNICKERBOCKER, NICOLE L (LPN)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:L
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 MAIN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2254
Mailing Address - Country:US
Mailing Address - Phone:607-621-0472
Mailing Address - Fax:
Practice Address - Street 1:183 MAIN ST APT 3
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2254
Practice Address - Country:US
Practice Address - Phone:607-621-0472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343820-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse