Healthcare Provider Details

I. General information

NPI: 1659103232
Provider Name (Legal Business Name): NICOLE MARIE WHITTAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AREA 27, BUILDING H200T
OCEANSIDE CA
92055
US

IV. Provider business mailing address

1545 LUKUP LN APT 101
COSTA MESA CA
92626-6709
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-0063
  • Fax:
Mailing address:
  • Phone: 714-483-5338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6727
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number30957
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: