Provider Demographics
NPI:1114719515
Name:FITZGERALD, NICKOLAS DESOUSA (CCHW)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:DESOUSA
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:CCHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SPENCER DR
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-1289
Mailing Address - Country:US
Mailing Address - Phone:774-328-2195
Mailing Address - Fax:
Practice Address - Street 1:823 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE VALLEY
Practice Address - State:RI
Practice Address - Zip Code:02832-1920
Practice Address - Country:US
Practice Address - Phone:401-539-2461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI200840172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker