Provider Demographics
NPI:1437620986
Name:AZAAN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:AZAAN
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 1:2015 GUM BRANCH RD APT 405
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4601
Mailing Address - Country:US
Mailing Address - Phone:646-450-1448
Mailing Address - Fax:208-978-5210
Practice Address - Street 1:2301 INDIAN DR APT 29C
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5258
Practice Address - Country:US
Practice Address - Phone:646-450-1448
Practice Address - Fax:208-978-5210
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No1744G0900XOther Service ProvidersSpecialistGraphics Designer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19009728OtherNATIONAL PROVIDER NUMBER