Provider Demographics
NPI:1255858197
Name:NICHOLS, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10526 DUBNOFF WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3921
Mailing Address - Country:US
Mailing Address - Phone:818-755-4950
Mailing Address - Fax:818-752-0783
Practice Address - Street 1:10526 DUBNOFF WAY
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3921
Practice Address - Country:US
Practice Address - Phone:818-755-4950
Practice Address - Fax:818-752-0783
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL