Provider Demographics
NPI:1538600549
Name:MCKELLOP, NICOLA JUANITA (FNP)
Entity type:Individual
Prefix:MRS
First Name:NICOLA
Middle Name:JUANITA
Last Name:MCKELLOP
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15982 PARKHOUSE DR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-6156
Mailing Address - Country:US
Mailing Address - Phone:626-314-0346
Mailing Address - Fax:
Practice Address - Street 1:2425 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3040
Practice Address - Country:US
Practice Address - Phone:909-481-7340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1417346388207R00000X
CA95008214363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine