Provider Demographics
NPI:1164068268
Name:NICKELSON, ESTHER YOON (FNP-C)
Entity Type:Individual
Prefix:
First Name:ESTHER
Middle Name:YOON
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 CLINTON AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6604
Mailing Address - Country:US
Mailing Address - Phone:406-209-1678
Mailing Address - Fax:
Practice Address - Street 1:411 GRAND AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-5022
Practice Address - Country:US
Practice Address - Phone:510-844-4097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-23
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT161968163W00000X
CA95154363163W00000X
CA95013748363LF0000X
MT161969363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1164068268Medicaid