Provider Demographics
NPI:1053484428
Name:NICOLAS, VANESSA ANN (CNM, RN)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:ANN
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:CNM, RN
Other - Prefix:MS
Other - First Name:VANESSA
Other - Middle Name:ANN
Other - Last Name:IWEKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, RN
Mailing Address - Street 1:1379 W PARK WESTERN DR
Mailing Address - Street 2:#262
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1379 W PARK WESTERN DR
Practice Address - Street 2:#262
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-2300
Practice Address - Country:US
Practice Address - Phone:310-403-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA724367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA724OtherCNM
CACOAFS-06-387208OtherBPPVE CERTIFICATE
CA356899OtherRN LISCENSE
AL1-043649OtherREGISTERED NURSE