Provider Demographics
NPI:1336613611
Name:PONICKI, REECE (RN)
Entity Type:Individual
Prefix:
First Name:REECE
Middle Name:
Last Name:PONICKI
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1873 W ENCINAS ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-2314
Mailing Address - Country:US
Mailing Address - Phone:480-204-7739
Mailing Address - Fax:
Practice Address - Street 1:1873 W ENCINAS ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-2314
Practice Address - Country:US
Practice Address - Phone:480-204-7739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN165385163WP0808X, 163WP2201X, 163WA0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)