Healthcare Provider Details

I. General information

NPI: 1811368921
Provider Name (Legal Business Name): NICOLE DEMELO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11024 BALBOA BLVD # 117
GRANADA HILLS CA
91344-5007
US

IV. Provider business mailing address

4145 VIA MARINA APT 108
MARINA DEL REY CA
90292
US

V. Phone/Fax

Practice location:
  • Phone: 508-951-7818
  • Fax:
Mailing address:
  • Phone: 508-951-7818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95007193
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number808615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: