Healthcare Provider Details

I. General information

NPI: 1548060080
Provider Name (Legal Business Name): NICOLE NANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI NANCE

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 B SOUTH CENTER DR.
CLEARLAKE CA
95422
US

IV. Provider business mailing address

PO BOX 1024
LUCERNE CA
95458-1024
US

V. Phone/Fax

Practice location:
  • Phone: 707-994-7090
  • Fax:
Mailing address:
  • Phone: 707-350-5723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: