Provider Demographics
NPI:1417179458
Name:GREENE, NICOLE ANGELIQUE (MA, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANGELIQUE
Last Name:GREENE
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANGELIQUE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-A
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5790
Mailing Address - Fax:
Practice Address - Street 1:1450 SAN PABLO ST STE 5100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5331
Practice Address - Country:US
Practice Address - Phone:323-442-5790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA4188237600000X
CAAU2169231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter