Healthcare Provider Details

I. General information

NPI: 1487920963
Provider Name (Legal Business Name): NICOLE LYN ROSENDALE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE M798 BOX 0114
SAN FRANCISCO CA
94143-0001
US

IV. Provider business mailing address

1001 POTRERO AVE BLDG 1
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 310-562-3511
  • Fax:
Mailing address:
  • Phone: 628-206-3762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number128038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: