=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083391684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FNU NISINA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2023
-----------------------------------------------------
Last Update Date | 07/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 W ROSE ST
-----------------------------------------------------
City | WALLA WALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99362-1662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-525-6650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 W ROSE ST
-----------------------------------------------------
City | WALLA WALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99362-1662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-525-0247
-----------------------------------------------------
Fax | 509-552-2349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7825
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DE61429179
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------