MEDICARE: NICOLE SIMONE SHELTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker		NV

General Provider Information

NPI Number	:	1942742424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE SIMONE SHELTON

Provider Business Mailing Address
First Line	:	1406 BASINBROOK ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89032
Country	:	US
Telephone Number	:	725-200-8764
Fax Number	:

Provider Business Practice Location Address
First Line	:	1406 BASIN BROOK DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-7850
Country	:	US
Telephone Number	:	725-200-8764
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2016
Last Update Date	:	11/15/2016

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Directions to “ NICOLE SIMONE SHELTON ” Practice Location

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