Healthcare Provider Details

I. General information

NPI: 1679081871
Provider Name (Legal Business Name): NICOLE MARIE BALDENEGRO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 02/05/2022
Certification Date: 02/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N F AVE
DOUGLAS AZ
85607-1919
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-3285
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-6882
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN200817
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number270094
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: