Provider Demographics
NPI:1396370953
Name:SAGE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SAGE
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 1:17350 STATE HIGHWAY 249 STE 220
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77064-1132
Mailing Address - Country:US
Mailing Address - Phone:407-782-9094
Mailing Address - Fax:
Practice Address - Street 1:17350 STATE HIGHWAY 249 STE 220
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77064-1132
Practice Address - Country:US
Practice Address - Phone:407-782-9094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0000000000000000Medicaid
TX00000000000000OtherNURSING SERVICE RELATED PROVIDERS TYPE