Healthcare Provider Details

I. General information

NPI: 1912813726
Provider Name (Legal Business Name): NICOLE SUE ALINE SHOOK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 SUPERIOR AVE STE 230
NEWPORT BEACH CA
92663-2779
US

IV. Provider business mailing address

7562 ELLIS AVE APT C3
HUNTINGTON BEACH CA
92648-1601
US

V. Phone/Fax

Practice location:
  • Phone: 949-645-7870
  • Fax:
Mailing address:
  • Phone: 714-478-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95033263
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number95033263
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number95033263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: