MEDICARE: NICOLE KIRSTY QUISPE

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	103K00000X	Behavior Analyst	LBA0966	NV

General Provider Information

NPI Number	:	1154956282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE KIRSTY QUISPE

Provider Business Mailing Address
First Line	:	350 5TH AVE STE 6115
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10118-6002
Country	:	US
Telephone Number	:	718-215-5311
Fax Number	:	904-647-2295

Provider Business Practice Location Address
First Line	:	7365 PRAIRIE FALCON RD STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0808
Country	:	US
Telephone Number	:	702-766-9840
Fax Number	:

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

Provider Enumeration Date	:	03/09/2020
Last Update Date	:	11/20/2025

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