MEDICARE: MEGAN COLLEEN NUCKOLS FNP

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	363L00000X	Nurse Practitioner	95028759	CA

General Provider Information

NPI Number	:	1457112880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN COLLEEN NUCKOLS FNP

Provider Business Mailing Address
First Line	:	11008 QUINNAULT RD
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-9405
Country	:	US
Telephone Number	:	951-795-5653
Fax Number	:

Provider Business Practice Location Address
First Line	:	11008 QUINNAULT RD
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92308-9405
Country	:	US
Telephone Number	:	951-795-5653
Fax Number	:

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

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	01/22/2024

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