Provider Demographics
NPI:1407689870
Name:NICOLA, MARY JEEN (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JEEN
Last Name:NICOLA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-3683
Mailing Address - Country:US
Mailing Address - Phone:724-864-9595
Mailing Address - Fax:724-864-9860
Practice Address - Street 1:905 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-3683
Practice Address - Country:US
Practice Address - Phone:724-864-9595
Practice Address - Fax:724-864-9860
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP030310363L00000X
FLAPRN11034854363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1044722540001Medicaid
PA850277OtherPA BS
PACA3219OtherPALMETTO GBA - RAILROAD MEDICARE