Provider Demographics
NPI:1174517122
Name:NICHOLAS, MARNI L (MD)
Entity type:Individual
Prefix:MRS
First Name:MARNI
Middle Name:L
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1080 E INDIANTOWN RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-5100
Mailing Address - Country:US
Mailing Address - Phone:561-741-5566
Mailing Address - Fax:561-295-5237
Practice Address - Street 1:1080 E INDIANTOWN RD
Practice Address - Street 2:SUITE 206
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-5100
Practice Address - Country:US
Practice Address - Phone:561-741-5566
Practice Address - Fax:561-295-5237
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH12286207R00000X
NY229705207R00000X
FLME123735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204330Medicaid
NH420610099Medicaid
NH3082849Medicaid
NH3082849Medicaid
NH30204330Medicaid
NHRE7718Medicare PIN