Provider Demographics
NPI:1154910255
Name:MART, NICOLE DAWN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:MART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BORDEN RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-5700
Mailing Address - Country:US
Mailing Address - Phone:760-415-7149
Mailing Address - Fax:
Practice Address - Street 1:330 BORDEN RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-5700
Practice Address - Country:US
Practice Address - Phone:760-415-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA641130163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse