Healthcare Provider Details

I. General information

NPI: 1104737311
Provider Name (Legal Business Name): NICHOLAS CAMERON CORY-DUFFY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 QUAIL ST STE 245
NEWPORT BEACH CA
92660-2749
US

IV. Provider business mailing address

8605 SANTA MONICA BLVD # 472934
WEST HOLLYWOOD CA
90069-4109
US

V. Phone/Fax

Practice location:
  • Phone: 949-594-4795
  • Fax: 949-994-4694
Mailing address:
  • Phone: 720-633-0566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95041497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: