Provider Demographics
NPI:1649588534
Name:WILDE, NICOLE DAWN (LAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:WILDE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 W GONZALES RD STE 170
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-0701
Mailing Address - Country:US
Mailing Address - Phone:805-407-1034
Mailing Address - Fax:
Practice Address - Street 1:750 W GONZALES RD STE 170
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0701
Practice Address - Country:US
Practice Address - Phone:805-407-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13210171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist