Healthcare Provider Details

I. General information

NPI: 1134184021
Provider Name (Legal Business Name): LAVONNE RAE NICKEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 PLUMAS BLVD SUITE 202
YUBA CITY CA
95991-5005
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 209-956-7732
  • Fax: 530-749-5520
Mailing address:
  • Phone: 530-320-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG52307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: