Provider Demographics
NPI:1982319133
Name:EGGOLD, NICOLE MARIE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:EGGOLD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 BROOKS AVE
Mailing Address - Street 2:1/2
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291
Mailing Address - Country:US
Mailing Address - Phone:949-547-1945
Mailing Address - Fax:
Practice Address - Street 1:526 BROOKS AVE
Practice Address - Street 2:1/2
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291
Practice Address - Country:US
Practice Address - Phone:949-547-1945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023380363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily