Provider Demographics
NPI:1568961621
Name:NICOLAS, CHARLOTTE STEPHANIE (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:STEPHANIE
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:STEPHANIE
Other - Last Name:LASSALAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4401 ATLANTIC AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2252
Mailing Address - Country:US
Mailing Address - Phone:562-988-2777
Mailing Address - Fax:562-988-2779
Practice Address - Street 1:4401 ATLANTIC AVE STE 202
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2252
Practice Address - Country:US
Practice Address - Phone:562-988-2777
Practice Address - Fax:562-988-2779
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily