Provider Demographics
NPI:1720726920
Name:RENGIFO, NICOLE
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:RENGIFO
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 1:357 AVENUE P
Mailing Address - Street 2:APT D8
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204
Mailing Address - Country:US
Mailing Address - Phone:646-881-2226
Mailing Address - Fax:
Practice Address - Street 1:420 95TH ST, BROOKLYN, NY 11209
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209
Practice Address - Country:US
Practice Address - Phone:646-881-2226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111322104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker