Healthcare Provider Details

I. General information

NPI: 1639015548
Provider Name (Legal Business Name): NYCOLE COLVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CREEKSIDE RIDGE SUITE 280 ROSEVILLE, CA 95678
ROSEVILLE CA
95678
US

IV. Provider business mailing address

1075 CREEKSIDE RIDGE SUITE 280 ROSEVILLE, CA 95678
ROSEVILLE CA
95678
US

V. Phone/Fax

Practice location:
  • Phone: 916-729-3098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: