Healthcare Provider Details

I. General information

NPI: 1932776531
Provider Name (Legal Business Name): NICOLE L NOBLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 RABBITBRUSH DR
FARMINGTON NM
87402-4574
US

IV. Provider business mailing address

2705 RABBITBRUSH DR
FARMINGTON NM
87402-4574
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-9002
  • Fax:
Mailing address:
  • Phone: 505-436-0095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: