Provider Demographics
NPI:1083175475
Name:DENNIS, NICOLE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DENNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-2517
Mailing Address - Country:US
Mailing Address - Phone:315-801-8534
Mailing Address - Fax:
Practice Address - Street 1:111 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-2517
Practice Address - Country:US
Practice Address - Phone:315-917-9966
Practice Address - Fax:315-234-3998
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1768542085R0202X
COTL.0007572390200000X
VA0116038848390200000X
NY3384262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program