Healthcare Provider Details

I. General information

NPI: 1982172003
Provider Name (Legal Business Name): NICOLE E BELLISARIO DNP, PMHNP-BC, CNL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 09/15/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W BROADWAY STE 400
SAN DIEGO CA
92101-3554
US

IV. Provider business mailing address

402 W BROADWAY STE 400
SAN DIEGO CA
92101-3554
US

V. Phone/Fax

Practice location:
  • Phone: 888-777-9409
  • Fax: 888-999-6614
Mailing address:
  • Phone: 888-777-9409
  • Fax: 888-999-6614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95022579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: