Provider Demographics
NPI:1407495914
Name:NUSSBAUM, RACHEL MALLIE (LAC)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:MALLIE
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 18TH ST APT 13
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6460
Mailing Address - Country:US
Mailing Address - Phone:904-583-7473
Mailing Address - Fax:
Practice Address - Street 1:3405 PENROSE PL STE 206
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1820
Practice Address - Country:US
Practice Address - Phone:904-583-7473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002515171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist