Provider Demographics
NPI:1548357692
Name:POLIQUIN, NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:POLIQUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FAIRBURN AVE
Mailing Address - Street 2:SUITE #105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5958
Mailing Address - Country:US
Mailing Address - Phone:310-474-8388
Mailing Address - Fax:
Practice Address - Street 1:1800 FAIRBURN AVE
Practice Address - Street 2:SUITE #105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5958
Practice Address - Country:US
Practice Address - Phone:310-474-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA304192084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA84086Medicare UPIN