Provider Demographics
NPI:1619701620
Name:NISCO, NOELLE
Entity type:Individual
Prefix:
First Name:NOELLE
Middle Name:
Last Name:NISCO
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 1:6255 W SUNSET BLVD FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7422
Mailing Address - Country:US
Mailing Address - Phone:323-860-5200
Mailing Address - Fax:
Practice Address - Street 1:475 ATLANTIC AVE STE 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-4383
Practice Address - Country:US
Practice Address - Phone:917-246-7498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY954558163W00000X
CA95381021163W00000X
GARN323785163W00000X
NY356143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse