Basic Information
| Provider Information | |||||||||
| NPI: | 1093154072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEMANN | ||||||||
| FirstName: | NICKI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 W THOMAS RD | ||||||||
| Address2: | # 301 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850138581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024066262 | ||||||||
| FaxNumber: | 6024066261 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 W THOMAS RD | ||||||||
| Address2: | # 301 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850138581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024066262 | ||||||||
| FaxNumber: | 6024066261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2013 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 575192 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 57232 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.