Provider Demographics
NPI:1972906998
Name:PALUMBO, NICOLE MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:PALUMBO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:GOODBREAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:18000 STUDEBAKER RD STE 800
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2671
Mailing Address - Country:US
Mailing Address - Phone:562-735-3226
Mailing Address - Fax:
Practice Address - Street 1:12370 HESPERIA RD STE 17
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5808
Practice Address - Country:US
Practice Address - Phone:760-388-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-04
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108180363AM0700X
CATPA10001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical