Healthcare Provider Details

I. General information

NPI: 1629336292
Provider Name (Legal Business Name): SHALEEN NICHOLS C.N.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2787 S KEY BISCAYNE DR
GILBERT AZ
85295-6076
US

IV. Provider business mailing address

2787 S KEY BISCAYNE DR
GILBERT AZ
85295-6076
US

V. Phone/Fax

Practice location:
  • Phone: 602-919-1700
  • Fax:
Mailing address:
  • Phone: 602-919-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA464099033
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: