Provider Demographics
NPI:1326640996
Name:SUE, NICOLE RUIZ
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RUIZ
Last Name:SUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S 18TH ST UNIT 702
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6133
Mailing Address - Country:US
Mailing Address - Phone:510-501-9381
Mailing Address - Fax:
Practice Address - Street 1:1408 S BROAD ST FL 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-4808
Practice Address - Country:US
Practice Address - Phone:215-467-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021681363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care