Provider Demographics
NPI:1245879865
Name:VAISMAN, NICOLE RACHEL
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RACHEL
Last Name:VAISMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 ALTON PKWY APT 229
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2184
Mailing Address - Country:US
Mailing Address - Phone:760-613-6587
Mailing Address - Fax:
Practice Address - Street 1:602 N EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4720
Practice Address - Country:US
Practice Address - Phone:949-369-5281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA78429OtherBOARD CERTIFIED REGISTERED PHARMACIST