Provider Demographics
NPI:1962725853
Name:SCOTT, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SCOTT
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 1:3880 BAYBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1503
Mailing Address - Country:US
Mailing Address - Phone:516-409-6922
Mailing Address - Fax:
Practice Address - Street 1:3880 BAYBERRY LN
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1503
Practice Address - Country:US
Practice Address - Phone:516-409-6922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046107183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist