Healthcare Provider Details

I. General information

NPI: 1275240376
Provider Name (Legal Business Name): NICOLE GRACE NOBLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-3100
  • Fax:
Mailing address:
  • Phone: 626-993-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW116468
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: