MEDICARE: NICOLE SOPHIA DERSAHAKIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		OK

General Provider Information

NPI Number	:	1184557977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE SOPHIA DERSAHAKIAN

Provider Business Mailing Address
First Line	:	12100 SHADOW RIDGE WAY
Second Line	:
City	:	PORTER RANCH
State	:	CA
Zip	:	91326-3827
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12100 SHADOW RIDGE WAY
Second Line	:
City	:	PORTER RANCH
State	:	CA
Zip	:	91326-3827
Country	:	US
Telephone Number	:	818-807-5374
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2026
Last Update Date	:	06/03/2026

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