Healthcare Provider Details

I. General information

NPI: 1306471644
Provider Name (Legal Business Name): LEA NICKOLAS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 N 3RD ST STE 212
PHOENIX AZ
85004-1145
US

IV. Provider business mailing address

2601 N 3RD ST STE 212
PHOENIX AZ
85004-1145
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-6970
  • Fax:
Mailing address:
  • Phone: 602-888-6970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number256708
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number183839-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: