Provider Demographics
NPI:1952870354
Name:NICOLOSO, NANCY CAROLINA (NP-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:CAROLINA
Last Name:NICOLOSO
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 1:708 PRAIRIE TIMBER RD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7687
Mailing Address - Country:US
Mailing Address - Phone:817-504-8334
Mailing Address - Fax:
Practice Address - Street 1:6302 LAKE WORTH BLVD STE A3963
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3607
Practice Address - Country:US
Practice Address - Phone:817-237-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP13782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine