Provider Demographics
NPI:1275151367
Name:ARREDONDO, NICOLE GRACELLA (RDA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRACELLA
Last Name:ARREDONDO
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 E VICTORIA ST SPC 412
Mailing Address - Street 2:
Mailing Address - City:RANCHO DOMINGUEZ
Mailing Address - State:CA
Mailing Address - Zip Code:90220-6823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 S ALAMEDA ST # A
Practice Address - Street 2:
Practice Address - City:RANCHO DOMINGUEZ
Practice Address - State:CA
Practice Address - Zip Code:90220-4976
Practice Address - Country:US
Practice Address - Phone:310-627-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA86440126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA86440Medicaid