Provider Demographics
NPI:1831626365
Name:GLATHE, NICOLE (LAC DIPLOM)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GLATHE
Suffix:
Gender:F
Credentials:LAC DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 VETERAN AVE APT 371
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4854
Mailing Address - Country:US
Mailing Address - Phone:707-337-9912
Mailing Address - Fax:
Practice Address - Street 1:915 S CATALINA AVE STE B
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-4795
Practice Address - Country:US
Practice Address - Phone:707-337-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17658171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist