1164648556 NPI number — MADONNA A NICOLAI CFNP

Table of content: MADONNA A NICOLAI CFNP (NPI 1164648556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164648556 NPI number — MADONNA A NICOLAI CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICOLAI
Provider First Name:
MADONNA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164648556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14351 MYFORD RD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-7045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-550-9990
Provider Business Mailing Address Fax Number:
714-550-1226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14351 MYFORD RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-7045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-550-9990
Provider Business Practice Location Address Fax Number:
714-550-1226
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  RN235360 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 6499 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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