Provider Demographics
NPI:1609308758
Name:MOTAKEF, NICOLE ROUSE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROUSE
Last Name:MOTAKEF
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:CHRISTINA
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:500 S ANAHEIM HILLS RD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4780
Mailing Address - Country:US
Mailing Address - Phone:949-414-9495
Mailing Address - Fax:
Practice Address - Street 1:500 S ANAHEIM HILLS RD STE 246
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-4760
Practice Address - Country:US
Practice Address - Phone:949-414-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A167932084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program