Individual
NICOLE MATEO LICUP NAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
11301 WILSHIRE BLVD # 117, LOS ANGELES, CA 90073-1003
(562) 261-7638
Mailing address
11301 WILSHIRE BLVD, LOS ANGELES, CA 90073-1003
(657) 224-0465
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
95085049
CA
363LP2300X
Primary Care Nurse Practitioner
Primary
95015421
CA
Other
Enumeration date
12/02/2021
Last updated
02/08/2022
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