Healthcare Provider Details

I. General information

NPI: 1124502273
Provider Name (Legal Business Name): NICOLE ANGELINA HENNIGAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ANGELINA RICCI RN

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42302 N VISION WAY STE 114
ANTHEM AZ
85086-1468
US

IV. Provider business mailing address

42302 N VISION WAY STE 114
ANTHEM AZ
85086-1468
US

V. Phone/Fax

Practice location:
  • Phone: 623-570-2162
  • Fax:
Mailing address:
  • Phone: 623-570-2162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number220086
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN161920
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: