Healthcare Provider Details

I. General information

NPI: 1669666889
Provider Name (Legal Business Name): NICOLE ANTONIA FABRIS-CARRAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE ANTONIA FABRIS M.D.

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E. CHEVY CHASE DR. #250
GLENDALE CA
91206
US

IV. Provider business mailing address

1500 E. CHEVY CHASE DR. #250
GLENDALE CA
91206
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2432
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA94252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: