Healthcare Provider Details

I. General information

NPI: 1073303715
Provider Name (Legal Business Name): NICHOLE MICHELLE MCDERMOTT CADC-I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W CHARLESTON BLVD
LAS VEGAS NV
89102-2205
US

IV. Provider business mailing address

2121 W CHARLESTON BLVD
LAS VEGAS NV
89102-2205
US

V. Phone/Fax

Practice location:
  • Phone: 702-382-7746
  • Fax:
Mailing address:
  • Phone: 702-382-7746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRSS-5215
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberCHW1-6217
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number08120-I
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: