Healthcare Provider Details

I. General information

NPI: 1841758372
Provider Name (Legal Business Name): NICOLE MARIE MIXAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17810 WELCH PLZ
OMAHA NE
68135-1620
US

IV. Provider business mailing address

7261 MERCY RD
OMAHA NE
68124-2311
US

V. Phone/Fax

Practice location:
  • Phone: 888-333-7520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112726
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: