Provider Demographics
NPI:1609428598
Name:MARK, NICOLE WHITNEY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:WHITNEY
Last Name:MARK
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 1:5030 CAMINO DE LA SIESTA STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3118
Mailing Address - Country:US
Mailing Address - Phone:858-455-5524
Mailing Address - Fax:858-587-9377
Practice Address - Street 1:5030 CAMINO DE LA SIESTA STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3118
Practice Address - Country:US
Practice Address - Phone:858-455-5524
Practice Address - Fax:858-587-9377
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
CA57109363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical