Provider Demographics
NPI:1023718673
Name:TRIVISO, NICHOLAS JEFFREY
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JEFFREY
Last Name:TRIVISO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13121 MARLETTE DR
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1907
Mailing Address - Country:US
Mailing Address - Phone:562-756-9555
Mailing Address - Fax:
Practice Address - Street 1:3600 LOMITA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3900
Practice Address - Country:US
Practice Address - Phone:310-977-2705
Practice Address - Fax:310-564-2295
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95030444363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program