Provider Demographics
NPI:1457332199
Name:NICCUM, SHERYL (NP)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:NICCUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18275 N 59TH AVENUE
Mailing Address - Street 2:BLDG K, SUITE 162
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308
Mailing Address - Country:US
Mailing Address - Phone:602-547-8184
Mailing Address - Fax:602-547-8339
Practice Address - Street 1:18275 N 59TH AVENUE
Practice Address - Street 2:BLDG K, SUITE 162
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308
Practice Address - Country:US
Practice Address - Phone:602-547-8184
Practice Address - Fax:602-547-8339
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZAP2438363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ488740Medicaid
135093Medicare PIN