Healthcare Provider Details

I. General information

NPI: 1609558428
Provider Name (Legal Business Name): NIKKIA WELLS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKIA BENNETT

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 VILLA LA JOLLA DR STE C217
LA JOLLA CA
92037-1712
US

IV. Provider business mailing address

3835 N FREEWAY BLVD STE 100
SACRAMENTO CA
95834-1954
US

V. Phone/Fax

Practice location:
  • Phone: 855-427-2778
  • Fax: 858-638-8142
Mailing address:
  • Phone: 916-576-7900
  • Fax: 858-638-8142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95061022
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95026956
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: