Basic Information
| Provider Information | |||||||||
| NPI: | 1770141541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICO | ||||||||
| FirstName: | NINA | ||||||||
| MiddleName: | TUTU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 VICEROY DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796988 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 N WASHINGTON AVE STE 7000 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2019 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP142118 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | 841610 | TX | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 841610 | 01 | TX | NURSES LICENSE | OTHER |