Provider Demographics
NPI:1164648556
Name:NICOLAI, MADONNA A (CFNP)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:A
Last Name:NICOLAI
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14351 MYFORD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7045
Mailing Address - Country:US
Mailing Address - Phone:714-550-9990
Mailing Address - Fax:714-550-1226
Practice Address - Street 1:14351 MYFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7045
Practice Address - Country:US
Practice Address - Phone:714-550-9990
Practice Address - Fax:714-550-1226
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN235360207R00000X
CA6499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMN1199238OtherDEA #
CAMN1199238OtherDEA #
CABJ139WMedicare UPIN