Provider Demographics
NPI:1770338469
Name:GLAZE, NICHOLE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:GLAZE
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 1:8337 5TH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3859
Mailing Address - Country:US
Mailing Address - Phone:562-896-2203
Mailing Address - Fax:
Practice Address - Street 1:6330 RUGBY AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4066
Practice Address - Country:US
Practice Address - Phone:562-896-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist