Provider Demographics
NPI:1316095557
Name:CORBETT, NICOLE J (LAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:CORBETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:NICKY
Other - Middle Name:J
Other - Last Name:CORBETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:1430 N AVON ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-1817
Mailing Address - Country:US
Mailing Address - Phone:818-845-1926
Mailing Address - Fax:
Practice Address - Street 1:10651 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2341
Practice Address - Country:US
Practice Address - Phone:818-506-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 7292171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist