Healthcare Provider Details

I. General information

NPI: 1932028297
Provider Name (Legal Business Name): ELISABETH NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9055 BALBOA AVE
SAN DIEGO CA
92123-1509
US

IV. Provider business mailing address

38238 COPPERWOOD ST
MURRIETA CA
92562-3417
US

V. Phone/Fax

Practice location:
  • Phone: 951-365-4171
  • Fax:
Mailing address:
  • Phone: 951-365-4171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: