Provider Demographics
NPI:1386719896
Name:PAVLIDES, NICOLE (CNM)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:PAVLIDES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:2595 N WYATT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-795-9912
Mailing Address - Fax:520-795-9934
Practice Address - Street 1:2595 N WYATT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6104
Practice Address - Country:US
Practice Address - Phone:520-795-9912
Practice Address - Fax:520-795-9934
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176972176B00000X
AZRN154574176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ390332Medicaid
GA536923623AMedicaid