Individual
JACQUELINE CHANTAL NICOLICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RPA-C
Contact information
Practice address
MEETING HOUSE LANE MEDICAL PRACTICE, PC SURGICAL SPEC., 240, SOUTHAMPTON, NY 11968
(631) 726-8717
(631) 726-8720
Mailing address
4 SPRINGVILLE RD STE B, HAMPTON BAYS, NY 11946-2290
(631) 726-8717
(631) 726-8720
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
020637
NY
Other
Enumeration date
02/28/2017
Last updated
04/21/2025
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