Provider Demographics
NPI:1275262214
Name:NICHOLAS, MICHAEL KIAMOS (RN, MSN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KIAMOS
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:RN, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 ADELINE ST STE 280
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2580
Mailing Address - Country:US
Mailing Address - Phone:510-981-4100
Mailing Address - Fax:
Practice Address - Street 1:3075 ADELINE ST.
Practice Address - Street 2:#280
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703
Practice Address - Country:US
Practice Address - Phone:510-981-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95019631363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health