Provider Demographics
NPI:1316633654
Name:HESSABI, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HESSABI
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 1:11262 CAMPUS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1727
Mailing Address - Country:US
Mailing Address - Phone:909-558-1000
Mailing Address - Fax:
Practice Address - Street 1:11262 CAMPUS ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1727
Practice Address - Country:US
Practice Address - Phone:909-558-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95032909363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program