Provider Demographics
NPI:1861924516
Name:DAISA, NICOLE MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DAISA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 LENNON LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2443
Mailing Address - Country:US
Mailing Address - Phone:925-433-8786
Mailing Address - Fax:925-433-8788
Practice Address - Street 1:575 LENNON LN
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2443
Practice Address - Country:US
Practice Address - Phone:925-433-8786
Practice Address - Fax:925-433-8788
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95415429163W00000X
WARN60666816163W00000X
WAAP60782216363LF0000X
CA95035040363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2106150Medicaid