Provider Demographics
NPI:1427171008
Name:NICKLESS, CAROL CRISTMAN (RN, PHN, BSN)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:CRISTMAN
Last Name:NICKLESS
Suffix:
Gender:F
Credentials:RN, PHN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12366 GRANDEE CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2120
Mailing Address - Country:US
Mailing Address - Phone:858-676-0096
Mailing Address - Fax:
Practice Address - Street 1:12366 GRANDEE CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2120
Practice Address - Country:US
Practice Address - Phone:858-676-0096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA536023163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health