Healthcare Provider Details

I. General information

NPI: 1952486243
Provider Name (Legal Business Name): BEVERLY B NICKERSON N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 28TH ST STE 318
LONG BEACH CA
90806-2785
US

IV. Provider business mailing address

701 E 28TH ST STE 318
LONG BEACH CA
90806-2785
US

V. Phone/Fax

Practice location:
  • Phone: 562-290-8888
  • Fax:
Mailing address:
  • Phone: 562-290-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberNP # 12061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: