Healthcare Provider Details

I. General information

NPI: 1023734738
Provider Name (Legal Business Name): SUSANNA EMILIA NICKEL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 W DEER VALLEY RD
GLENDALE AZ
85308-2002
US

IV. Provider business mailing address

3575 W DEER VALLEY RD
GLENDALE AZ
85308-2002
US

V. Phone/Fax

Practice location:
  • Phone: 480-585-5200
  • Fax:
Mailing address:
  • Phone: 480-585-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9395
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: