Healthcare Provider Details

I. General information

NPI: 1073638367
Provider Name (Legal Business Name): DESPINA COLETTE NICOLAOU M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 WILSHIRE BLVD 5TH FLOOR, CHILDRENS HOSPITAL LOS ANGELES
LOS ANGELES CA
90010-1577
US

IV. Provider business mailing address

9625 BLACKGOLD RD
LA JOLLA CA
92037-1111
US

V. Phone/Fax

Practice location:
  • Phone: 323-669-2350
  • Fax: 323-669-7081
Mailing address:
  • Phone: 310-351-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: