Healthcare Provider Details

I. General information

NPI: 1457934465
Provider Name (Legal Business Name): NICOLE BURGOS WILLIAMS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 K ST STE 410
SACRAMENTO CA
95816-5119
US

IV. Provider business mailing address

1257 56TH AVE
SACRAMENTO CA
95831-3146
US

V. Phone/Fax

Practice location:
  • Phone: 916-389-7100
  • Fax:
Mailing address:
  • Phone: 562-565-9163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number95017049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: