Provider Demographics
NPI:1235654443
Name:LOLLIE, NADINE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:
Last Name:LOLLIE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15263 S 14TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-6260
Mailing Address - Country:US
Mailing Address - Phone:248-894-4039
Mailing Address - Fax:
Practice Address - Street 1:15263 S 14TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-6260
Practice Address - Country:US
Practice Address - Phone:248-894-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN199310163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty