Provider Demographics
NPI:1407114606
Name:LEARNED, NICOLE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEARNED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BON AIR RD STE 105
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1137
Mailing Address - Country:US
Mailing Address - Phone:415-461-0440
Mailing Address - Fax:
Practice Address - Street 1:5 BON AIR RD STE 105
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1137
Practice Address - Country:US
Practice Address - Phone:415-461-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2024-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA130347208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program