Provider Demographics
NPI:1760482574
Name:NIKOLIC, CHRISTINE NDUNGE (NP-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:NDUNGE
Last Name:NIKOLIC
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 E. ARBOR AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-641-5400
Mailing Address - Fax:480-218-4353
Practice Address - Street 1:6116 E. ARBOR AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-641-5400
Practice Address - Fax:480-218-4353
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN121750163W00000X
AZAP1691363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00418321OtherRAILROAD MEDICARE
AZP00150020OtherRAILROAD MEDICARE
AZWCSKQOtherSUN HEALTH GROUP #
AZ836356Medicaid
AZQ09915Medicare UPIN
AZZ78738Medicare PIN