Healthcare Provider Details

I. General information

NPI: 1508480120
Provider Name (Legal Business Name): NICOLE MORALDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SUMMIT ST STE 2549
OAKLAND CA
94609-3412
US

IV. Provider business mailing address

3200 BENJAMIN DR
RICHMOND CA
94806-2773
US

V. Phone/Fax

Practice location:
  • Phone: 510-869-6656
  • Fax:
Mailing address:
  • Phone: 510-589-0536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013826
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95158487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: