Healthcare Provider Details

I. General information

NPI: 1245496967
Provider Name (Legal Business Name): JANET MARIE NICKS RN, CNOR, RNFA, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 01/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

990 E HATTIE GREENE
FLAGSTAFF AZ
86001-1918
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2130
  • Fax:
Mailing address:
  • Phone: 928-779-5565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP5377
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN067070
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: