Healthcare Provider Details

I. General information

NPI: 1538827985
Provider Name (Legal Business Name): NICOLE MATEO LICUP NAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MATEO LICUP NP

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 02/08/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD # 117
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 562-261-7638
  • Fax:
Mailing address:
  • Phone: 657-224-0465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95015421
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95085049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: