Healthcare Provider Details

I. General information

NPI: 1063106805
Provider Name (Legal Business Name): MYRIAME MIA NICOLAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 04/19/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 C AVE
CORONADO CA
92118-1420
US

IV. Provider business mailing address

158 C AVE
CORONADO CA
92118-1420
US

V. Phone/Fax

Practice location:
  • Phone: 619-435-5400
  • Fax:
Mailing address:
  • Phone: 619-435-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95024480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: