Provider Demographics
NPI:1972321628
Name:MAZMANIAN, NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MAZMANIAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 VISTA MIRAGE WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1906
Mailing Address - Country:US
Mailing Address - Phone:760-413-0295
Mailing Address - Fax:
Practice Address - Street 1:82013 DOCTOR CARREON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-4832
Practice Address - Country:US
Practice Address - Phone:760-775-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily