Provider Demographics
NPI:1205996592
Name:RHODES, NICHOLE DOMINIQUE (LPN)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:DOMINIQUE
Last Name:RHODES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 STELLENWERF AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1128
Mailing Address - Country:US
Mailing Address - Phone:631-224-9186
Mailing Address - Fax:
Practice Address - Street 1:32 STELLENWERF AVE
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-1128
Practice Address - Country:US
Practice Address - Phone:631-224-9186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240822-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02730821Medicaid