Healthcare Provider Details

I. General information

NPI: 1346725090
Provider Name (Legal Business Name): NICKIE DIANE STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6205 43RD ST
LUBBOCK TX
79407-3828
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-749-2263
  • Fax: 806-749-2264
Mailing address:
  • Phone: 806-761-0334
  • Fax: 806-785-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP138166
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: