Healthcare Provider Details

I. General information

NPI: 1851121446
Provider Name (Legal Business Name): ANGELA NICOLE NICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CARMEL AVE NE STE 601
ALBUQUERQUE NM
87122-3125
US

IV. Provider business mailing address

6700 CANTATA ST NW UNIT 2802
ALBUQUERQUE NM
87114-6355
US

V. Phone/Fax

Practice location:
  • Phone: 505-677-8842
  • Fax: 505-717-1539
Mailing address:
  • Phone: 505-715-8056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00010176
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: