Provider Demographics
NPI:1629370382
Name:CHRISTIAN-GENIUS, NICOLE S (CNM, DM)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:S
Last Name:CHRISTIAN-GENIUS
Suffix:
Gender:F
Credentials:CNM, DM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:818-658-5980
Mailing Address - Fax:
Practice Address - Street 1:1808 VERDUGO BLVD STE 413
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1468
Practice Address - Country:US
Practice Address - Phone:818-658-5980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR152087367A00000X
CANMW236250367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1629370382Medicaid