Healthcare Provider Details

I. General information

NPI: 1043662356
Provider Name (Legal Business Name): NIKOLA MARIE NEILL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKOLA MARIE SCHAFER, LINNENKAMP

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 MCCULLOCH BLVD N STE 100
LAKE HAVASU CITY AZ
86403-6559
US

IV. Provider business mailing address

1760 MCCULLOCH BLVD N STE 100
LAKE HAVASU CITY AZ
86403-6559
US

V. Phone/Fax

Practice location:
  • Phone: 928-854-5368
  • Fax: 928-854-4462
Mailing address:
  • Phone: 928-854-5368
  • Fax: 928-854-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8722
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: