Provider Demographics
NPI:1679835748
Name:MAKSYMIW, NICOLE PRESTIANO (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:PRESTIANO
Last Name:MAKSYMIW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:PRESTIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 ELM ST STE 203A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2282
Mailing Address - Country:US
Mailing Address - Phone:203-212-9959
Mailing Address - Fax:203-646-6534
Practice Address - Street 1:324 ELM ST STE 203A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2282
Practice Address - Country:US
Practice Address - Phone:203-212-9959
Practice Address - Fax:203-646-6534
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT054258207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine