Provider Demographics
NPI:1184197311
Name:BISTRICEANU, NICULINA (MSN)
Entity Type:Individual
Prefix:
First Name:NICULINA
Middle Name:
Last Name:BISTRICEANU
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7615 MADDEN DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-9425
Mailing Address - Country:US
Mailing Address - Phone:208-440-1085
Mailing Address - Fax:
Practice Address - Street 1:7615 MADDEN DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-9425
Practice Address - Country:US
Practice Address - Phone:208-440-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID38220163WG0000X
ID64875363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner