Provider Demographics
NPI:1801498563
Name:NICKEL, AUDRA JAYNE
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:JAYNE
Last Name:NICKEL
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 1:1200 AVENIDA CESAR CHAVEZ SE APT 1811
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3902
Mailing Address - Country:US
Mailing Address - Phone:605-216-9164
Mailing Address - Fax:
Practice Address - Street 1:1200 AVENIDA CESAR CHAVEZ SE APT 1811
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3902
Practice Address - Country:US
Practice Address - Phone:605-216-9164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician