Provider Demographics
NPI:1093109738
Name:KOHAN, NICOLE ILANAH (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ILANAH
Last Name:KOHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9798 FOOTHILL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3692
Mailing Address - Country:US
Mailing Address - Phone:714-328-4159
Mailing Address - Fax:
Practice Address - Street 1:695 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3490
Practice Address - Country:US
Practice Address - Phone:099-625-7861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15243TLG152WC0802X, 152W00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Yes152W00000XEye and Vision Services ProvidersOptometrist