Provider Demographics
NPI:1962172106
Name:KIDIKIAN, ALINE (NP)
Entity type:Individual
Prefix:
First Name:ALINE
Middle Name:
Last Name:KIDIKIAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SUPERIOR AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3640
Mailing Address - Country:US
Mailing Address - Phone:949-642-4974
Mailing Address - Fax:
Practice Address - Street 1:1501 SUPERIOR AVE STE 205
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3640
Practice Address - Country:US
Practice Address - Phone:949-642-4974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-19
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily