Provider Demographics
NPI:1295396125
Name:MITRA, NICOLLETTE (FNP)
Entity Type:Individual
Prefix:
First Name:NICOLLETTE
Middle Name:
Last Name:MITRA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NICOLLETTE
Other - Middle Name:
Other - Last Name:GUILLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1871 CAMINO ESTRADA
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-2439
Mailing Address - Country:US
Mailing Address - Phone:925-285-2649
Mailing Address - Fax:
Practice Address - Street 1:2400 BALFOUR RD STE 302
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-4955
Practice Address - Country:US
Practice Address - Phone:925-285-2649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010361363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily