Basic Information
Provider Information
NPI: 1851860852
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NELSON
FirstName: NICOLE
MiddleName: LOREN
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 390 UNION BLVD STE 300
Address2:  
City: LAKEWOOD
State: CO
PostalCode: 80112
CountryCode: US
TelephoneNumber: 3039898172
FaxNumber: 3039844366
Practice Location
Address1: 12211 TITUS AVE
Address2:  
City: SARATOGA
State: CA
PostalCode: 950703456
CountryCode: US
TelephoneNumber: 6502768692
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/19/2018
LastUpdateDate: 11/19/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106E00000X CAY    

No ID Information.


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