Provider Demographics
NPI:1588387369
Name:BAIN, NICOLE (LE)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BAIN
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2256 HEAVENLY WAY
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4490
Mailing Address - Country:US
Mailing Address - Phone:209-274-7857
Mailing Address - Fax:
Practice Address - Street 1:9117 E STOCKTON BLVD, UNIT 100, SUITE 19
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624
Practice Address - Country:US
Practice Address - Phone:209-294-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9771174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty