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NICOLE MATEO LICUP NAM NP
NPI 1538827985
Nurse Practitioner - Primary Care in Los Angeles, CA

Active since December 02, 2021
11301 WILSHIRE BLVD # 117, LOS ANGELES, CA 90073(562) 261-7638 Get Directions Write a Review

NPPES record last updated: February 8, 2022. Verified against the NPPES registry weekly; last sync: July 26, 2026.

Record update history: Feb 8, 2022, Dec 2, 2021 (2 updates tracked since 2021).

About Nicole Mateo Licup Nam Np NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

NICOLE MATEO LICUP NAM NP (NPI 1538827985) is an individual primary care provider in Los Angeles, California, licensed in California (95015421) and active in the NPI registry since December 2021.

NPPES Registry Identity

NPI1538827985
Entity TypeIndividualFemale
Primary Taxonomy363LP2300X
Provider Legal NameNICOLE MATEO LICUP NAMCredential: NP
Location Address11301 WILSHIRE BLVD # 117Los Angeles, CA 90073-1003
Mailing Address11301 Wilshire BlvdLos Angeles, CA 90073-1003 · (657) 224-0465
Phone(562) 261-7638
Sole ProprietorNo
Enumeration DateDecember 2, 2021
Last NPPES UpdateFebruary 8, 20222 updates tracked since enumeration
NPPES CertifiedJanuary 29, 2022
✔ NPI 1538827985 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyNurse Practitioner · Primary CarePhysician Assistants & Advanced Practice Nursing Providers
Taxonomy Code363LP2300X
License✔ Licensed in CA · 95015421
Also ListedRegistered NurseTaxonomy 163W00000X · License 95085049 (CA)
11301 WILSHIRE BLVD # 117, Los Angeles, CA 90073
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Other Names 1

Former Name (1)Nicole Mateo Licup Np

Other Providers at the Same Location NPPES 8

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

RYAN MCCARTY M.D.
Physical Medicine & Rehabilitation (Pain Medicine)
11301 WILSHIRE BLVD # 117
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711
AGNES SORIANO WALLBOM M.D., M.S.
Physical Medicine & Rehabilitation
11301 WILSHIRE BLVD # 117, GLAVAHS DEPT PM&R
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711
BERTHEL POWELL BA/RKT
Kinesiotherapist
11301 WILSHIRE BLVD # 117
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711
WEST LOS ANGELES VA
Rehabilitation Hospital
11301 WILSHIRE BLVD # 117
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711
MISS SHANA SCHULLER FRIEDMAN OTR
Occupational Therapist
11301 WILSHIRE BLVD # 117
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711
MELISSA ERIN PHUPHANICH MD, MS
Student in an Organized Health Care Education/Training Program
11301 WILSHIRE BLVD # 117
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711
DR. DAVID ARTHUR BENTON D.O.
Physical Medicine & Rehabilitation
11301 WILSHIRE BLVD # 117
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711
MRS. DEBORAH LYNN CORNWELL OTR/L
Occupational Therapist
11301 WILSHIRE BLVD # 117
LOS ANGELES, CA 90073
Los Angeles County (310) 478-3711

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Nicole Licup Nam's NPI number?

The NPI number for Nicole Licup Nam is 1538827985. It was assigned to this individual provider in the NPPES registry on December 2, 2021. The provider is also known as Nicole Mateo Licup Np.

Where is Nicole Licup Nam located?

Nicole Licup Nam practices at 11301 Wilshire Blvd # 117, Los Angeles, CA 90073. The listed phone number is (562) 261-7638.

What is Nicole Licup Nam's specialty?

The primary specialty registered for this NPI is Nurse Practitioner, specializing in Primary Care, with taxonomy code 363LP2300X.

When was this NPI record last updated?

The NPPES record for Nicole Licup Nam was last updated on February 8, 2022. NPI Profile syncs with the weekly NPPES data releases published by CMS.