Provider Demographics
NPI:1891373262
Name:NICHOLSON, DWANA ANJEL (NP)
Entity Type:Individual
Prefix:
First Name:DWANA
Middle Name:ANJEL
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11107 S VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2554
Mailing Address - Country:US
Mailing Address - Phone:310-892-1472
Mailing Address - Fax:
Practice Address - Street 1:11107 S VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-2554
Practice Address - Country:US
Practice Address - Phone:310-892-1472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA626142363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care