Provider Demographics
NPI:1063106805
Name:NICOLAS, MYRIAME MIA (NP)
Entity type:Individual
Prefix:MS
First Name:MYRIAME
Middle Name:MIA
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 SANTA MARIA CT
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5823
Mailing Address - Country:US
Mailing Address - Phone:760-626-5927
Mailing Address - Fax:
Practice Address - Street 1:192 SANTA MARIA CT
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5823
Practice Address - Country:US
Practice Address - Phone:760-626-5927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95024480363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health