Provider Demographics
NPI:1598233306
Name:BALLANTYNE, NINA MILLS (CNM)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:MILLS
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:BALLANTYNE
Other - Last Name:TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1017 DAMASCUS CIR
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1608
Mailing Address - Country:US
Mailing Address - Phone:413-687-9263
Mailing Address - Fax:714-707-4119
Practice Address - Street 1:1017 DAMASCUS CIR
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1608
Practice Address - Country:US
Practice Address - Phone:413-687-9263
Practice Address - Fax:714-707-4119
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA367A00000X
CA95010744363LW0102X
CA235994367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467590901Medicaid