Basic Information
| Provider Information | |||||||||
| NPI: | 1285665570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKLES | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | PANDORA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4318 MISSION AVE | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920576541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609015010 | ||||||||
| FaxNumber: | 7607222204 | ||||||||
| Practice Location | |||||||||
| Address1: | 4318 MISSION AVE | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920576541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609015010 | ||||||||
| FaxNumber: | 7607222204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 05/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS004879L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02713300 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 0459530 | 01 | PA | AETNA | OTHER | 22143 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 2713300 | 01 | PA | KHP CENTRAL | OTHER | 431452 | 01 | PA | CAPITAL BLUE SHIELD | OTHER |