Healthcare Provider Details

I. General information

NPI: 1275881500
Provider Name (Legal Business Name): NICOLE SELLERS LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2414 ASHBY AVE STE 201
BERKELEY CA
94705-2063
US

IV. Provider business mailing address

5408 MORENGO DR
CONCORD CA
94521-5009
US

V. Phone/Fax

Practice location:
  • Phone: 501-655-2229
  • Fax:
Mailing address:
  • Phone: 925-408-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM 122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: