Provider Demographics
NPI:1922412063
Name:NA, NICOLE J (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:J
Last Name:NA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 S WESTERN AVE
Mailing Address - Street 2:STE 229
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-1084
Mailing Address - Country:US
Mailing Address - Phone:213-385-9100
Mailing Address - Fax:
Practice Address - Street 1:3250 W OLYMPIC BLVD STE 221
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2368
Practice Address - Country:US
Practice Address - Phone:323-766-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist