Healthcare Provider Details

I. General information

NPI: 1164342036
Provider Name (Legal Business Name): NICOLE RAYDENE LEOS LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 CAMFIELD AVE
COMMERCE CA
90040-1574
US

IV. Provider business mailing address

2040 CAMFIELD AVE
COMMERCE CA
90040-1574
US

V. Phone/Fax

Practice location:
  • Phone: 323-725-8751
  • Fax:
Mailing address:
  • Phone: 323-725-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number760596
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: