Provider Demographics
NPI:1124502273
Name:HENNIGAN, NICOLE ANGELINA (FNP-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANGELINA
Last Name:HENNIGAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANGELINA
Other - Last Name:RICCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:24820 N 16TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0643
Mailing Address - Country:US
Mailing Address - Phone:623-570-2162
Mailing Address - Fax:
Practice Address - Street 1:24820 N 16TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-0643
Practice Address - Country:US
Practice Address - Phone:623-570-2162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN161920163W00000X
AZ220086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse