Provider Demographics
NPI:1689768533
Name:WHEELER, NICOLE (DOM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:STE. L-1
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2143
Mailing Address - Country:US
Mailing Address - Phone:505-988-9509
Mailing Address - Fax:505-988-8082
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:STE. L-1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-988-9509
Practice Address - Fax:505-988-8082
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM428171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00R73ZOtherBC/BS PROVIDER ID