Healthcare Provider Details

I. General information

NPI: 1962907352
Provider Name (Legal Business Name): NICOLE NATSUMI NOOTBAAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 ARENA ST
EL SEGUNDO CA
90245-3016
US

IV. Provider business mailing address

538 ARENA ST
EL SEGUNDO CA
90245-3016
US

V. Phone/Fax

Practice location:
  • Phone: 310-357-4586
  • Fax:
Mailing address:
  • Phone: 310-357-4586
  • 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: