Provider Demographics
NPI:1780102053
Name:AL-SHAFIE, NICOLE DESIREE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DESIREE
Last Name:AL-SHAFIE
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 1:3215 OVERLAND AVE APT 8167
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-4546
Mailing Address - Country:US
Mailing Address - Phone:424-345-2123
Mailing Address - Fax:
Practice Address - Street 1:620 N BRAND BLVD STE 401
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1210
Practice Address - Country:US
Practice Address - Phone:424-345-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1013062133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered