Provider Demographics
NPI:1710368964
Name:ONTIVEROS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ONTIVEROS
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 1:10396 BELLEGRAVE AVE
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-1921
Mailing Address - Country:US
Mailing Address - Phone:626-297-9194
Mailing Address - Fax:
Practice Address - Street 1:10396 BELLEGRAVE AVE
Practice Address - Street 2:
Practice Address - City:MIRA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91752-1921
Practice Address - Country:US
Practice Address - Phone:626-297-9194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-13
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95060485163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse