Healthcare Provider Details

I. General information

NPI: 1629757109
Provider Name (Legal Business Name): NICHOLE RAYLEEN PRADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6736 LAUREL CANYON BLVD STE 200
NORTH HOLLYWOOD CA
91606-1576
US

IV. Provider business mailing address

919 1ST ST
SAN FERNANDO CA
91340-2957
US

V. Phone/Fax

Practice location:
  • Phone: 818-326-1208
  • Fax:
Mailing address:
  • Phone: 818-326-1208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: