Healthcare Provider Details

I. General information

NPI: 1184197311
Provider Name (Legal Business Name): NICULINA BISTRICEANU MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7615 MADDEN DR
NAMPA ID
83686-9425
US

IV. Provider business mailing address

7615 MADDEN DR
NAMPA ID
83686-9425
US

V. Phone/Fax

Practice location:
  • Phone: 208-440-1085
  • Fax:
Mailing address:
  • Phone: 208-440-1085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number64875
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number64875
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number38220
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: