Provider Demographics
NPI:1679128615
Name:BERRIOS, NICOLE (LAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BERRIOS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SIGNORETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2034 S ALMA SCHOOL RD STE 4
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4004
Mailing Address - Country:US
Mailing Address - Phone:480-712-7032
Mailing Address - Fax:
Practice Address - Street 1:2034 S ALMA SCHOOL RD STE 4
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4004
Practice Address - Country:US
Practice Address - Phone:480-712-7032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0935171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty