Healthcare Provider Details

I. General information

NPI: 1891669628
Provider Name (Legal Business Name): CLOTELLA NIKKI SOMERVILLE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 MAPLE AVE
LOS ANGELES CA
90014-2211
US

IV. Provider business mailing address

655 MAPLE AVE
LOS ANGELES CA
90014-2211
US

V. Phone/Fax

Practice location:
  • Phone: 323-244-6720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: