Healthcare Provider Details

I. General information

NPI: 1609585116
Provider Name (Legal Business Name): NICOLE NATIVIDAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2022
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 MERCURY WAY STE 107
SANTA ROSA CA
95407-5472
US

IV. Provider business mailing address

2235 MERCURY WAY STE 107
SANTA ROSA CA
95407-5472
US

V. Phone/Fax

Practice location:
  • Phone: 707-494-0762
  • Fax:
Mailing address:
  • Phone: 707-494-0762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-FUSKZE
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: