Healthcare Provider Details

I. General information

NPI: 1356695373
Provider Name (Legal Business Name): NICOLE MARIE KISSLING RN, NP, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MARIE GARRETT

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

224 17TH PL
MANHATTAN BEACH CA
90266-4642
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-0697
  • Fax: 310-423-0127
Mailing address:
  • Phone: 614-352-6518
  • Fax: 310-423-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number22152
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number3821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: