Provider Demographics
NPI:1457710220
Name:NICKSIC, TRINA
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:
Last Name:NICKSIC
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 1:1830 LAPORTE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2341
Mailing Address - Country:US
Mailing Address - Phone:970-416-6240
Mailing Address - Fax:970-472-2369
Practice Address - Street 1:1830 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2341
Practice Address - Country:US
Practice Address - Phone:970-416-6240
Practice Address - Fax:970-472-2369
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002024275124Q00000X
WI10636-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist