Provider Demographics
NPI:1306942719
Name:FANELLI, NICOLE (NP)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:FANELLI
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 1:4700 INGLEWOOD BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5896
Mailing Address - Country:US
Mailing Address - Phone:818-606-3565
Mailing Address - Fax:
Practice Address - Street 1:4700 INGLEWOOD BLVD STE 102
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-5896
Practice Address - Country:US
Practice Address - Phone:818-606-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16846363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily