Provider Demographics
NPI:1053471052
Name:NICKLAS, CATHI THERESA (FNP)
Entity Type:Individual
Prefix:
First Name:CATHI
Middle Name:THERESA
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:424-315-2728
Mailing Address - Fax:424-315-2729
Practice Address - Street 1:8767 WILSHIRE BLVD FL 3
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2714
Practice Address - Country:US
Practice Address - Phone:424-315-2728
Practice Address - Fax:424-315-2729
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336229363LF0000X
CANP16307363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily