Healthcare Provider Details

I. General information

NPI: 1962057562
Provider Name (Legal Business Name): NICOLE KJOLBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SAMUEL MERRITT COLLEGE, 370 HAWTHORNE AVE
OAKLAND CA
94609
US

IV. Provider business mailing address

254 DIVISADERO ST APT 1
SAN FRANCISCO CA
94117-3256
US

V. Phone/Fax

Practice location:
  • Phone: 510-869-6511
  • Fax:
Mailing address:
  • Phone: 650-773-7793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95062609
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001729
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: