Provider Demographics
NPI:1598380545
Name:BALLEW, NINA GABRIELLE (OD)
Entity type:Individual
Prefix:DR
First Name:NINA
Middle Name:GABRIELLE
Last Name:BALLEW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:GABRIELLE
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1720 S MICHIGAN AVE APT 917
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4892
Mailing Address - Country:US
Mailing Address - Phone:806-928-5260
Mailing Address - Fax:
Practice Address - Street 1:4411 THE 25 WAY NE STE 325
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5853
Practice Address - Country:US
Practice Address - Phone:505-888-5757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist