Provider Demographics
NPI:1093154072
Name:NIEMANN, NICKI (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKI
Middle Name:
Last Name:NIEMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W THOMAS RD
Mailing Address - Street 2:# 301
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-8581
Mailing Address - Country:US
Mailing Address - Phone:602-406-6262
Mailing Address - Fax:602-406-6261
Practice Address - Street 1:240 W THOMAS RD
Practice Address - Street 2:# 301
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-8581
Practice Address - Country:US
Practice Address - Phone:602-406-6262
Practice Address - Fax:602-406-6261
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-23
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5751922084N0400X
AZ572322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty