Healthcare Provider Details

I. General information

NPI: 1417726209
Provider Name (Legal Business Name): NICOLE MARIE WINNIE MSN, RN, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 N TUSTIN AVE
SANTA ANA CA
92705-7817
US

IV. Provider business mailing address

1901 N TUSTIN AVE
SANTA ANA CA
92705-7817
US

V. Phone/Fax

Practice location:
  • Phone: 657-859-5463
  • Fax: 909-495-1300
Mailing address:
  • Phone: 657-859-5463
  • Fax: 909-495-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95027089
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95027089
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number790048
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: