Provider Demographics
NPI:1467645549
Name:MAGANO, NICOLE SHARISE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHARISE
Last Name:MAGANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 MERCED ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1810
Mailing Address - Country:US
Mailing Address - Phone:559-981-2795
Mailing Address - Fax:
Practice Address - Street 1:3333 N BOND AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-5712
Practice Address - Country:US
Practice Address - Phone:559-229-3529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10107600OtherMEDICAL