Provider Demographics
NPI:1730255811
Name:NICHOLSON, GAY (CNM)
Entity type:Individual
Prefix:
First Name:GAY
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 W CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5266
Mailing Address - Country:US
Mailing Address - Phone:607-342-1630
Mailing Address - Fax:
Practice Address - Street 1:413 W CLINTON ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5266
Practice Address - Country:US
Practice Address - Phone:607-342-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001039176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02240673Medicaid