Provider Demographics
NPI:1659936268
Name:PORTUE, NICOLE MANUELA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MANUELA
Last Name:PORTUE
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 1:7405 CHARMANT DR UNIT 2204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-5011
Mailing Address - Country:US
Mailing Address - Phone:415-424-7181
Mailing Address - Fax:
Practice Address - Street 1:1100 SPORTFISHER DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-2550
Practice Address - Country:US
Practice Address - Phone:670-276-0439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program