Provider Demographics
NPI:1134184021
Name:NICKEL, LAVONNE RAE (MD)
Entity type:Individual
Prefix:DR
First Name:LAVONNE
Middle Name:RAE
Last Name:NICKEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:530-320-0296
Mailing Address - Fax:
Practice Address - Street 1:460 PLUMAS BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-5005
Practice Address - Country:US
Practice Address - Phone:209-956-7732
Practice Address - Fax:530-749-5520
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2024-10-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG52307207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00253089OtherRAILROAD MEDICARE
CA00G523070OtherBLUE SHIELD OF CA
CA00G523070Medicaid
CAP00253089OtherRAILROAD MEDICARE
CA00G523070OtherBLUE SHIELD OF CA