Healthcare Provider Details

I. General information

NPI: 1144450495
Provider Name (Legal Business Name): ANNALEE NICOLLE NIX O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNALEE NICOLLE LOPEZ

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 W SOUTHERN AVE STE. 2242
MESA AZ
85202-4803
US

IV. Provider business mailing address

1450 E NANCY AVE
QUEEN CREEK AZ
85140-4052
US

V. Phone/Fax

Practice location:
  • Phone: 480-345-7520
  • Fax:
Mailing address:
  • Phone: 602-828-2517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1699
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: