Healthcare Provider Details

I. General information

NPI: 1750490645
Provider Name (Legal Business Name): NICOLE MARIE LANOUETTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 SYLVESTER RD BLDG 500
SAN DIEGO CA
92106-3521
US

IV. Provider business mailing address

140 SYLVESTER RD BLDG 500
SAN DIEGO CA
92106-3521
US

V. Phone/Fax

Practice location:
  • Phone: 619-553-0276
  • Fax: 619-553-9448
Mailing address:
  • Phone: 619-553-0276
  • Fax: 619-553-9448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA89709
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA89709
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: