Healthcare Provider Details

I. General information

NPI: 1144948068
Provider Name (Legal Business Name): JULIA NICOLE VICENCIO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28633 S WESTERN AVE STE 202
RANCHO PALOS VERDES CA
90275-0817
US

IV. Provider business mailing address

28633 S WESTERN AVE STE 202
RANCHO PALOS VERDES CA
90275-0817
US

V. Phone/Fax

Practice location:
  • Phone: 424-264-5286
  • Fax:
Mailing address:
  • Phone: 424-264-5286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95040111
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: