Provider Demographics
NPI:1417536913
Name:ILAGAN, NICOLE DEOTOY
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DEOTOY
Last Name:ILAGAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 CANBY AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-2979
Mailing Address - Country:US
Mailing Address - Phone:818-921-3466
Mailing Address - Fax:
Practice Address - Street 1:7601 CANBY AVE STE 3
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-2979
Practice Address - Country:US
Practice Address - Phone:818-921-3466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-03
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 373H00000X
CA171M00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health Worker
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty