Provider Demographics
NPI:1043805401
Name:DE ANGELIS, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DE ANGELIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4068 WHITE ASH RD
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-0447
Mailing Address - Country:US
Mailing Address - Phone:626-736-8932
Mailing Address - Fax:
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-788-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily