MEDICARE: NICOLE WALSH

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	172V00000X	Community Health Worker
2	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1568125284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE WALSH

Provider Business Mailing Address
First Line	:	10200 SEPULVEDA BLVD STE 170
Second Line	:
City	:	MISSION HILLS
State	:	CA
Zip	:	91345-3322
Country	:	US
Telephone Number	:	818-895-9707
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 N LANTANA ST STE 259
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-9008
Country	:	US
Telephone Number	:	805-910-8153
Fax Number	:

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

Provider Enumeration Date	:	10/19/2021
Last Update Date	:	04/16/2024

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Directions to “ NICOLE WALSH ” Practice Location

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