Healthcare Provider Details

I. General information

NPI: 1588001416
Provider Name (Legal Business Name): DESIREE ROCHELLE NYCHOLAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2013
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST LOMA LINDA UNIVERSITY MEDICAL CENTER, PEDIATRICS
LOMA LINDA CA
92350
US

IV. Provider business mailing address

11175 CAMPUS ST # A1111
LOMA LINDA CA
92350-1700
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4174
  • Fax:
Mailing address:
  • Phone: 909-558-4184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA135346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: