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General NPI Number Information
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NPI Number | 1598380545
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Entity Type | Individual
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Provider Name | NINA GABRIELLE BALLEW OD
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Gender | Female
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Dates
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Enumeration Date | 06/15/2020
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Last Update Date | 06/30/2020
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Provider Practice Location Address
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Address Line | 4411 THE 25 WAY NE STE 325
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-5853
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Country | US
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Telephone | 505-888-5757
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Fax |
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Provider Business Mailing Address
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Address Line | 1720 S MICHIGAN AVE APT 917
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City | CHICAGO
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State | IL
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Zip | 60616-4892
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Country | US
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Telephone | 806-928-5260
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046.011441
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License Number State | IL
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