Healthcare Provider Details

I. General information

NPI: 1760482574
Provider Name (Legal Business Name): CHRISTINE NDUNGE NIKOLIC NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6309 E BAYWOOD AVE STE 101
MESA AZ
85206-1726
US

IV. Provider business mailing address

6309 E BAYWOOD AVE STE 101
MESA AZ
85206-1726
US

V. Phone/Fax

Practice location:
  • Phone: 480-641-5400
  • Fax: 480-218-4353
Mailing address:
  • Phone: 480-641-5400
  • Fax: 480-218-4353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP1691
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN121750
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: