Provider Demographics
NPI:1992852537
Name:BRADSHAW, NICOLE (L AC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10061 RIVERSIDE DRIVE #811
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602
Mailing Address - Country:US
Mailing Address - Phone:818-509-9233
Mailing Address - Fax:818-509-9799
Practice Address - Street 1:11638 VENTURA BLVD
Practice Address - Street 2:UNIT B
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2653
Practice Address - Country:US
Practice Address - Phone:818-509-9233
Practice Address - Fax:818-509-9799
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAAC 8406171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist