Basic Information
| Provider Information | |||||||||
| NPI: | 1073638367 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOLAOU | ||||||||
| FirstName: | DESPINA | ||||||||
| MiddleName: | COLETTE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9625 BLACKGOLD RD | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103519880 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3250 WILSHIRE BLVD | ||||||||
| Address2: | 5TH FLOOR, CHILDRENS HOSPITAL LOS ANGELES | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900101577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236692350 | ||||||||
| FaxNumber: | 3236697081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.