Provider Demographics
NPI:1477144210
Name:GORDON-NICHOLS, ANGELA
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:GORDON-NICHOLS
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 1:34428 YUCAIPA BLVD STE E-176
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2474
Mailing Address - Country:US
Mailing Address - Phone:909-499-7138
Mailing Address - Fax:
Practice Address - Street 1:34428 YUCAIPA BLVD STE E-176
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2474
Practice Address - Country:US
Practice Address - Phone:909-499-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMADRIELLA374J00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoula