Provider Demographics
NPI:1063092419
Name:TFAYE, NICOLE MARY (DO)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARY
Last Name:TFAYE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28062 BAXTER RD
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-1401
Mailing Address - Country:US
Mailing Address - Phone:951-290-4168
Mailing Address - Fax:
Practice Address - Street 1:28780 SINGLE OAK DR STE 160
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5528
Practice Address - Country:US
Practice Address - Phone:951-723-3804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-10
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A20776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program