Provider Demographics
NPI:1255056537
Name:NICANOR, KATHLEEN ANNE ELEVAZO (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:KATHLEEN ANNE
Middle Name:ELEVAZO
Last Name:NICANOR
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2647 S BARRINGTON AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2852
Mailing Address - Country:US
Mailing Address - Phone:510-493-8448
Mailing Address - Fax:
Practice Address - Street 1:2647 S BARRINGTON AVE APT 9
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2852
Practice Address - Country:US
Practice Address - Phone:510-493-8448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP455752183500000X
CARPH86761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist