Provider Demographics
NPI:1336905306
Name:BALTAZAR, NICOLE TAYE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:TAYE
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 FAIRMILE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-9361
Mailing Address - Country:US
Mailing Address - Phone:336-254-8797
Mailing Address - Fax:
Practice Address - Street 1:517 FAIRMILE DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-9361
Practice Address - Country:US
Practice Address - Phone:336-254-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health