Provider Demographics
NPI:1437802162
Name:KING, NICHOLE A
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:A
Last Name:KING
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 1:2577 W GREENWAY RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-4308
Mailing Address - Country:US
Mailing Address - Phone:602-375-1777
Mailing Address - Fax:602-993-0588
Practice Address - Street 1:2577 W GREENWAY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-4308
Practice Address - Country:US
Practice Address - Phone:602-375-1777
Practice Address - Fax:602-993-0588
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALM012210376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81-860132OtherASSISTED LIVING