Healthcare Provider Details

I. General information

NPI: 1477067015
Provider Name (Legal Business Name): PATRICIA MARIE NICHOLS DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4532
US

IV. Provider business mailing address

9611 LAGRIMA DE ORO RD NE
ALBUQUERQUE NM
87111-2523
US

V. Phone/Fax

Practice location:
  • Phone: 323-420-4269
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: