Healthcare Provider Details

I. General information

NPI: 1275262214
Provider Name (Legal Business Name): MICHAEL KIAMOS NICHOLAS RN, MSN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 ADELINE ST. #280
BERKELEY CA
94703
US

IV. Provider business mailing address

3075 ADELINE ST STE 280
BERKELEY CA
94703-2580
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-4100
  • Fax:
Mailing address:
  • Phone: 510-981-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95019631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: