MEDICARE: NANCY CAROLINA NICOLOSO NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	AP13782	TX

General Provider Information

NPI Number	:	1952870354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY CAROLINA NICOLOSO NP-C

Provider Business Mailing Address
First Line	:	708 PRAIRIE TIMBER RD
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-7687
Country	:	US
Telephone Number	:	817-504-8334
Fax Number	:

Provider Business Practice Location Address
First Line	:	6302 LAKE WORTH BLVD STE A3963
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-3607
Country	:	US
Telephone Number	:	817-237-8273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2018
Last Update Date	:	11/15/2018

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