MEDICARE: MISS NICHOLE RAE MOSHER

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	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04111971	OTHER	CA	COUNSELOR

General Provider Information

NPI Number	:	1710273024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NICHOLE RAE MOSHER

Provider Business Mailing Address
First Line	:	491 NANNETTE ST
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3801
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 3RD AVE
Second Line	:	C3
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3139
Country	:	US
Telephone Number	:	619-691-8164
Fax Number	:

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

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	06/24/2011

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