Basic Information
| Provider Information | |||||||||
| NPI: | 1053471052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKLAS | ||||||||
| FirstName: | CATHI | ||||||||
| MiddleName: | THERESA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 N MARTEL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900466611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234365019 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 S GRAND AVE STE 801 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2137419727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F336229 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.