Provider Demographics
NPI:1083391684
Name:NISINA, FNU
Entity Type:Individual
Prefix:
First Name:FNU
Middle Name:
Last Name:NISINA
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 1:1120 W ROSE ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1662
Mailing Address - Country:US
Mailing Address - Phone:509-525-0247
Mailing Address - Fax:509-552-2349
Practice Address - Street 1:1120 W ROSE ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1662
Practice Address - Country:US
Practice Address - Phone:509-525-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7825122300000X
WADE61429179122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist