Healthcare Provider Details

I. General information

NPI: 1275386443
Provider Name (Legal Business Name): NICOLE RENEE PALMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 SAN LUIS
SAN LUIS OBISPO CA
93409-0001
US

IV. Provider business mailing address

6251 MCKNIGHT DR
LAKEWOOD CA
90713-2026
US

V. Phone/Fax

Practice location:
  • Phone: 805-547-7900
  • Fax:
Mailing address:
  • Phone: 562-298-2085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: