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General NPI Number Information
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NPI Number | 1538827985
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Entity Type | Individual
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Provider Name | NICOLE MATEO LICUP NAM NP
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Gender | Female
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Dates
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Enumeration Date | 12/02/2021
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Last Update Date | 02/08/2022
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Provider Practice Location Address
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Address Line | 11301 WILSHIRE BLVD # 117
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City | LOS ANGELES
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State | CA
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Zip | 90073-1003
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Country | US
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Telephone | 562-261-7638
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Fax |
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Provider Business Mailing Address
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Address Line | 11301 WILSHIRE BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90073-1003
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Country | US
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Telephone | 657-224-0465
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 95015421
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 95085049
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License Number State | CA
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