Basic Information
| Provider Information | |||||||||
| NPI: | 1477941722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | DORCAS | ||||||||
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| Credential: | ANP-GNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105772547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146075730 | ||||||||
| FaxNumber: | 9146075726 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106042901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146826532 | ||||||||
| FaxNumber: | 9146815260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2015 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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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 | 163W00000X | 591905 | NY | N | Nursing Service Providers | Registered Nurse | 363LG0600X | F340912 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | F306443 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 04080291 | 05 | NY | MEDICAID |