Provider Demographics
NPI:1598223174
Name:MIKULA, NICOLE (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MIKULA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 ROUTE 9W STE 10
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1370
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:275 CHENANGO ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2312
Practice Address - Country:US
Practice Address - Phone:607-201-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020889363LP0808X
NY402704363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07630615Medicaid