MEDICARE: KARLA ANGELICA NICOLAS APCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician		CA
2	101YM0800X	Mental Health Counselor	12399	CA

General Provider Information

NPI Number	:	1063045730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARLA ANGELICA NICOLAS APCC

Provider Business Mailing Address
First Line	:	8765 AERO DR STE 310A
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1767
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5025 COLLWOOD BLVD APT 3316
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-2126
Country	:	US
Telephone Number	:	415-994-2309
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	11/09/2022

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