Healthcare Provider Details

I. General information

NPI: 1619891439
Provider Name (Legal Business Name): NICOLE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3936 CASTELLINA WAY
MANTECA CA
95337-8454
US

IV. Provider business mailing address

3936 CASTELLINA WAY
MANTECA CA
95337-8454
US

V. Phone/Fax

Practice location:
  • Phone: 209-568-1391
  • Fax:
Mailing address:
  • Phone: 209-568-1391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95446287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: