Provider Demographics
NPI:1558131581
Name:NICHOLS, COQUEECE
Entity Type:Individual
Prefix:
First Name:COQUEECE
Middle Name:
Last Name: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 1:5870 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2037
Mailing Address - Country:US
Mailing Address - Phone:951-683-6596
Mailing Address - Fax:
Practice Address - Street 1:5870 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2037
Practice Address - Country:US
Practice Address - Phone:951-683-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30028167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician