Healthcare Provider Details

I. General information

NPI: 1942946397
Provider Name (Legal Business Name): NICOLE VIENNEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4508 N SABINO MOUNTAIN DR
TUCSON AZ
85750-6924
US

IV. Provider business mailing address

4508 N SABINO MOUNTAIN DR
TUCSON AZ
85750-6924
US

V. Phone/Fax

Practice location:
  • Phone: 817-412-1872
  • Fax:
Mailing address:
  • Phone: 817-412-1872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN134145
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: