Provider Demographics
NPI:1184203820
Name:NIDDAM, GERALDINE SARAH (RN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:SARAH
Last Name:NIDDAM
Suffix:
Gender:F
Credentials:RN, CPNP-PC
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:6327 MCCALLUM BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-4011
Mailing Address - Country:US
Mailing Address - Phone:469-328-7021
Mailing Address - Fax:
Practice Address - Street 1:12221 MERIT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2202
Practice Address - Country:US
Practice Address - Phone:214-253-8170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1011414363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics