Healthcare Provider Details

I. General information

NPI: 1952102451
Provider Name (Legal Business Name): MANDY ELIZABETH NANKIVEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2025
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 E BROADWAY STE 314
LONG BEACH CA
90802-7801
US

IV. Provider business mailing address

5211 FINO DR
SAN DIEGO CA
92124-2013
US

V. Phone/Fax

Practice location:
  • Phone: 619-838-7400
  • Fax:
Mailing address:
  • Phone: 619-838-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: