Provider Demographics
NPI:1073852265
Name:PRIES, NICOLE ANNE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:PRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 SCOTT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:JBPHH-HICKAM AFB
Mailing Address - State:HI
Mailing Address - Zip Code:96853
Mailing Address - Country:US
Mailing Address - Phone:808-448-6354
Mailing Address - Fax:
Practice Address - Street 1:755 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96853-5399
Practice Address - Country:US
Practice Address - Phone:808-448-6354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX743440363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics