Provider Demographics
NPI:1609419639
Name:LEE, NICHOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:LEE
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 1:13504 N 154TH LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-9160
Mailing Address - Country:US
Mailing Address - Phone:623-262-7721
Mailing Address - Fax:
Practice Address - Street 1:5750 W THUNDERBIRD RD STE C300
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4666
Practice Address - Country:US
Practice Address - Phone:623-238-7490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-22
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN161542163WX0200X
AZ235410363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WX0200XNursing Service ProvidersRegistered NurseOncologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner