Basic Information
| Provider Information | |||||||||
| NPI: | 1063708659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIDLA | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5130 E MAIN STREET RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140203496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853441421 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5130 E MAIN STREET RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140203496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853441421 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 485166-1 | NY | Y | Agencies | Community/Behavioral Health |
No ID Information.