Healthcare Provider Details

I. General information

NPI: 1528242294
Provider Name (Legal Business Name): GRACE AURORE NICKSA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UCLA MEDICAL PLZ STE 265
LOS ANGELES CA
90095-5724
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-2429
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number234436
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberA113138
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberW0970
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: