Provider Demographics
NPI:1619341831
Name:RALSTON, NICOLE L (AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:RALSTON
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:THEVENOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31235
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1235
Mailing Address - Country:US
Mailing Address - Phone:520-324-2308
Mailing Address - Fax:
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-324-1205
Practice Address - Fax:520-324-3650
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-26
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8413363LG0600X, 363LA2200X
MDRN113296163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WH1000XNursing Service ProvidersRegistered NurseHospice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ489037Medicaid