Provider Demographics
NPI:1093917106
Name:NICOLAY, LESLI IZELLA
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:IZELLA
Last Name:NICOLAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11370 ANDERSON ST
Mailing Address - Street 2:SUITE 2050
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2735
Mailing Address - Fax:909-558-2731
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:SUITE 2050
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2735
Practice Address - Fax:909-558-2731
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98098208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology