Provider Demographics
NPI:1558008136
Name:NICHOLSON, FAITH N
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:N
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FAITH
Other - Middle Name:NOEL
Other - Last Name:MCALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:58471 29 PALMS HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-5818
Mailing Address - Country:US
Mailing Address - Phone:857-760-4888
Mailing Address - Fax:
Practice Address - Street 1:58471 29 PALMS HWY STE 102
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-5818
Practice Address - Country:US
Practice Address - Phone:760-853-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X
CAMPSS-OVWSLE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator