Provider Demographics
NPI:1073846754
Name:NICOLAS, NINA CHRISTIE (NP)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:CHRISTIE
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:CARUNUNGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:146 BLAZE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618
Mailing Address - Country:US
Mailing Address - Phone:949-981-1602
Mailing Address - Fax:
Practice Address - Street 1:700 S TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-3425
Practice Address - Country:US
Practice Address - Phone:714-922-4177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN713659363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA713659Medicaid
CANP19255Medicaid