Healthcare Provider Details

I. General information

NPI: 1407563356
Provider Name (Legal Business Name): NICOLE MORELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 CARRILLO DR STE 103
LOS ANGELES CA
90048-5400
US

IV. Provider business mailing address

924 W BEACH AVE APT 10
INGLEWOOD CA
90302-7348
US

V. Phone/Fax

Practice location:
  • Phone: 310-854-0529
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number48654
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: