Healthcare Provider Details

I. General information

NPI: 1508186644
Provider Name (Legal Business Name): NICOLE ANASTASIA SPOONER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 JULIA ST
BERKELEY CA
94703
US

IV. Provider business mailing address

1612 JULIA ST
BERKELEY CA
94703-2018
US

V. Phone/Fax

Practice location:
  • Phone: 415-307-4566
  • Fax: 415-206-4153
Mailing address:
  • Phone: 415-307-4566
  • Fax: 415-206-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number755783
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: