Healthcare Provider Details

I. General information

NPI: 1124784939
Provider Name (Legal Business Name): NICOLETTE HARRIDGE RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W GALLERIA DR
HENDERSON NV
89011-4800
US

IV. Provider business mailing address

111 S GIBSON RD APT 3312
HENDERSON NV
89012-2670
US

V. Phone/Fax

Practice location:
  • Phone: 702-963-7451
  • Fax:
Mailing address:
  • Phone: 702-626-3580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN35157
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: