Provider Demographics
NPI:1295405413
Name:VELASQUEZ, NICOLE JILLIAN (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JILLIAN
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JILLIAN
Other - Last Name:WYPYCHOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3000
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-3733
Practice Address - Country:US
Practice Address - Phone:323-865-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-18
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant