Provider Demographics
NPI:1134307200
Name:DAVIS, NICOLE ELIZABETH
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:DAVIS
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 1:11303 W WASHINGTON BLVD
Mailing Address - Street 2:#200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6003
Mailing Address - Country:US
Mailing Address - Phone:310-482-6607
Mailing Address - Fax:310-313-0813
Practice Address - Street 1:11303 W WASHINGTON BLVD
Practice Address - Street 2:#200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6003
Practice Address - Country:US
Practice Address - Phone:310-482-6607
Practice Address - Fax:310-313-0813
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner