Provider Demographics
NPI:1083850002
Name:DEWITT, NICOLE AMBER (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AMBER
Last Name:DEWITT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4633
Mailing Address - Country:US
Mailing Address - Phone:602-262-8900
Mailing Address - Fax:
Practice Address - Street 1:4331 E BASELINE RD
Practice Address - Street 2:SUITE B105-625
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2961
Practice Address - Country:US
Practice Address - Phone:480-981-0216
Practice Address - Fax:480-981-1151
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0610367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ157848Medicare PIN
AZZ180546Medicare UPIN