Provider Demographics
NPI:1629477922
Name:NIELSEN, NICOLE M (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-1328
Mailing Address - Country:US
Mailing Address - Phone:708-269-9389
Mailing Address - Fax:
Practice Address - Street 1:12756 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1626
Practice Address - Country:US
Practice Address - Phone:818-896-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA741191835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA74119OtherRPH
CA10301OtherADVANCED PRACTICE PHARMACIST