Provider Demographics
NPI:1124731880
Name:WASHINGTON, NICHELLE NICOLE I
Entity type:Individual
Prefix:PROF
First Name:NICHELLE
Middle Name:NICOLE
Last Name:WASHINGTON
Suffix:I
Gender:F
Credentials:
Other - Prefix:PROF
Other - First Name:NICHELLE
Other - Middle Name:NICOLE
Other - Last Name:WASHINGTON
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:MIRACLES HAIR STUDIO
Mailing Address - Street 1:2633 TELEGRAPH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1744
Mailing Address - Country:US
Mailing Address - Phone:510-663-1200
Mailing Address - Fax:
Practice Address - Street 1:2633 TELEGRAPH AVE STE 107
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1744
Practice Address - Country:US
Practice Address - Phone:510-663-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK3590171744P3200X
KK3590171744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management