Healthcare Provider Details

I. General information

NPI: 1417732017
Provider Name (Legal Business Name): NICOLE E WEISS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LINNIE CT
EDGEWOOD NM
87015-9125
US

IV. Provider business mailing address

1 LINNIE CT
EDGEWOOD NM
87015-9125
US

V. Phone/Fax

Practice location:
  • Phone: 505-286-7838
  • Fax: 505-286-8025
Mailing address:
  • Phone: 505-286-7838
  • Fax: 505-286-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7861
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: