Healthcare Provider Details

I. General information

NPI: 1932872595
Provider Name (Legal Business Name): LUCILLE VINCENT MCDERMOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CALLE DEL PRESIDENTE
BERNALILLO NM
87004-6091
US

IV. Provider business mailing address

121 CALLE DEL PRESIDENTE
BERNALILLO NM
87004-6091
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-2324
  • Fax:
Mailing address:
  • Phone: 505-238-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number64100
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: