Provider Demographics
NPI:1336722685
Name:NICKLER, AIKKIKO (IDC)
Entity Type:Individual
Prefix:
First Name:AIKKIKO
Middle Name:
Last Name:NICKLER
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 ORO VISTA RD APT 245
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-4507
Mailing Address - Country:US
Mailing Address - Phone:475-224-8659
Mailing Address - Fax:
Practice Address - Street 1:1741 ORO VISTA RD APT 245
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-4507
Practice Address - Country:US
Practice Address - Phone:475-224-8659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA13367226851710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336722685OtherTRICARE