Provider Demographics
NPI:1669139978
Name:DILLARD, NICOLE MITSUE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MITSUE
Last Name:DILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 EL MUNDO ST APT 1017
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-4645
Mailing Address - Country:US
Mailing Address - Phone:832-723-7990
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:281-441-2245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX867083163WE0003X
TX1080925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency