Provider Demographics
NPI:1639516644
Name:GLESINGER, NICOLE EVETTE (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:EVETTE
Last Name:GLESINGER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2748 N PACIFIC DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-4283
Mailing Address - Country:US
Mailing Address - Phone:520-247-3362
Mailing Address - Fax:520-623-7064
Practice Address - Street 1:2571 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2910
Practice Address - Country:US
Practice Address - Phone:520-247-3362
Practice Address - Fax:520-623-7064
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-16989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty