Healthcare Provider Details

I. General information

NPI: 1639750839
Provider Name (Legal Business Name): KARISTA NICHILO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S COUNTY LINE DR
CHAPARRAL NM
88081-7869
US

IV. Provider business mailing address

P.O. DRAWER 70
ANTHONY NM
88021
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-3156
  • Fax:
Mailing address:
  • Phone: 575-882-1018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN-90496
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: