Healthcare Provider Details

I. General information

NPI: 1700704541
Provider Name (Legal Business Name): NICO PEMANTLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 98TH AVE
OAKLAND CA
94603-2702
US

IV. Provider business mailing address

1800 98TH AVE
OAKLAND CA
94603-2702
US

V. Phone/Fax

Practice location:
  • Phone: 510-639-2888
  • Fax:
Mailing address:
  • Phone: 510-639-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number260001040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: