Provider Demographics
NPI:1427539410
Name:NESBITT, NICHOLE BEULAH
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:BEULAH
Last Name:NESBITT
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 1:9829 E BIRCHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-1878
Mailing Address - Country:US
Mailing Address - Phone:623-565-3500
Mailing Address - Fax:
Practice Address - Street 1:3701 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119-9301
Practice Address - Country:US
Practice Address - Phone:480-677-7519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP048010164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD07954245OtherDRIVER LICENSE