Provider Demographics
NPI:1144044603
Name:PAGE, NICHOLE R
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:R
Last Name:PAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-3679
Mailing Address - Country:US
Mailing Address - Phone:707-672-2349
Mailing Address - Fax:
Practice Address - Street 1:2355 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3679
Practice Address - Country:US
Practice Address - Phone:707-672-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician