Healthcare Provider Details

I. General information

NPI: 1609919224
Provider Name (Legal Business Name): NICOLE E. OGNIBENE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 S POPLAR AVE APT 7
BREA CA
92821-5585
US

IV. Provider business mailing address

286 S POPLAR AVE APT 7
BREA CA
92821-5585
US

V. Phone/Fax

Practice location:
  • Phone: 714-309-5129
  • Fax:
Mailing address:
  • Phone: 714-309-5129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: