Healthcare Provider Details

I. General information

NPI: 1457420077
Provider Name (Legal Business Name): NICOLETTE LEE BALLOU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8920 WILSHIRE BLVD STE 604
BEVERLY HILLS CA
90211
US

IV. Provider business mailing address

8920 WILSHIRE BLVD STE 604
BEVERLY HILLS CA
90211
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-7867
  • Fax: 310-659-0804
Mailing address:
  • Phone: 310-659-7867
  • Fax: 310-659-0804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG53313
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: