Healthcare Provider Details

I. General information

NPI: 1326640996
Provider Name (Legal Business Name): NICOLE RUIZ SUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 VISTA WAY BLDG. B, STE. 130
OCEANSIDE CA
92056-4565
US

IV. Provider business mailing address

3880 MURPHY CANYON RD STE 200
SAN DIEGO CA
92123-4411
US

V. Phone/Fax

Practice location:
  • Phone: 760-547-1010
  • Fax: 760-547-1011
Mailing address:
  • Phone: 858-502-1169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95015504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: