Healthcare Provider Details

I. General information

NPI: 1124061601
Provider Name (Legal Business Name): NICOLE ANN DAWSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE CHS B-186
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

5767 W. CENTURY BLVD #400
LOS ANGELES CA
90045-5655
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-8285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberA65764
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA65764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: