Healthcare Provider Details

I. General information

NPI: 1760128441
Provider Name (Legal Business Name): NICOLE GHANBARZADEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 JACKSON ST APT 906
OAKLAND CA
94612-4014
US

IV. Provider business mailing address

1735 MISSION ST
SAN FRANCISCO CA
94103-4014
US

V. Phone/Fax

Practice location:
  • Phone: 415-622-8107
  • Fax:
Mailing address:
  • Phone: 415-622-8107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number19258
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number85631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: