Provider Demographics
NPI:1881883502
Name:BOSSON, NICHOLE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:BOSSON
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 1:15221 MAGNOLIA BLVD
Mailing Address - Street 2:UNIT E
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON STREET BLDG D-9
Practice Address - Street 2:HARBOR UCLA
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502
Practice Address - Country:US
Practice Address - Phone:917-513-6038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115510207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine