Healthcare Provider Details

I. General information

NPI: 1609419639
Provider Name (Legal Business Name): NICHOLE LEE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 11/24/2023
Certification Date: 11/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W THUNDERBIRD RD STE C300
GLENDALE AZ
85306-4666
US

IV. Provider business mailing address

13504 N 154TH LN
SURPRISE AZ
85379-9160
US

V. Phone/Fax

Practice location:
  • Phone: 623-238-7490
  • Fax:
Mailing address:
  • Phone: 623-262-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number235410
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number235410
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN161542
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: