Basic Information
| Provider Information | |||||||||
| NPI: | 1760482574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIKOLIC | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | NDUNGE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6116 E. ARBOR AVE | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806415400 | ||||||||
| FaxNumber: | 4802184353 | ||||||||
| Practice Location | |||||||||
| Address1: | 6116 E. ARBOR AVE | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806415400 | ||||||||
| FaxNumber: | 4802184353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN121750 | AZ | N | Nursing Service Providers | Registered Nurse | 363LA2200X | AP1691 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | P00418321 | 01 | AZ | RAILROAD MEDICARE | OTHER | P00150020 | 01 | AZ | RAILROAD MEDICARE | OTHER | WCSKQ | 01 | AZ | SUN HEALTH GROUP # | OTHER | 836356 | 05 | AZ | MEDICAID |