MEDICARE: NICOLE MARIE LANOUETTE MD

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	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	A89709	CA
2	2084P0800X	Psychiatry Physician	A89709	CA

General Provider Information

NPI Number	:	1750490645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE LANOUETTE MD

Provider Business Mailing Address
First Line	:	140 SYLVESTER RD BLDG 500
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-3521
Country	:	US
Telephone Number	:	619-553-0276
Fax Number	:	619-553-9448

Provider Business Practice Location Address
First Line	:	140 SYLVESTER RD BLDG 500
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-3521
Country	:	US
Telephone Number	:	619-553-0276
Fax Number	:	619-553-9448

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	02/25/2021

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