Provider Demographics
NPI:1851121446
Name:NICKENS, ANGELA NICOLE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:NICKENS
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 1:6700 CANTATA ST NW UNIT 2802
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-6355
Mailing Address - Country:US
Mailing Address - Phone:505-715-8056
Mailing Address - Fax:
Practice Address - Street 1:8300 CARMEL AVE NE STE 601
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-3125
Practice Address - Country:US
Practice Address - Phone:505-677-8842
Practice Address - Fax:505-717-1539
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00010176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist