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General NPI Number Information
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NPI Number | 1962063859
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Entity Type | Individual
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Provider Name | NIDA KICHKLA NP
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Gender | Female
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Dates
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Enumeration Date | 06/22/2019
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Last Update Date | 06/21/2021
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Provider Practice Location Address
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Address Line | 510 S GRAND AVE STE 200
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City | GLENDORA
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State | CA
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Zip | 91741-4291
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Country | US
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Telephone | 626-914-1980
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Fax |
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Provider Business Mailing Address
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Address Line | 1010 N AVENUE 66
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City | LOS ANGELES
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State | CA
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Zip | 90042-1512
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Country | US
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Telephone | 626-374-9774
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95011993
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License Number State | CA
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