Provider Demographics
NPI:1447641147
Name:CLEMENT, NICOLE (RN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLEMENT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BOURDEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 417153
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-7153
Mailing Address - Country:US
Mailing Address - Phone:518-952-8140
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:55 ELM ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3549
Practice Address - Country:US
Practice Address - Phone:518-793-7273
Practice Address - Fax:518-798-5004
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6933050163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid