Provider Demographics
NPI:1801172614
Name:HOLLENBACK, NICELEE FALL (NPP)
Entity type:Individual
Prefix:
First Name:NICELEE
Middle Name:FALL
Last Name:HOLLENBACK
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 GOODBAND RD
Mailing Address - Street 2:
Mailing Address - City:FREEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13068-9651
Mailing Address - Country:US
Mailing Address - Phone:607-342-5728
Mailing Address - Fax:607-238-4687
Practice Address - Street 1:950 DANBY RD STE 202A
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5714
Practice Address - Country:US
Practice Address - Phone:607-342-5728
Practice Address - Fax:607-238-4687
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401500363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY401500OtherNPP
NY5344741OtherNY STATE RNP LICENSE