Provider Demographics
NPI:1144893645
Name:CLEVELAND, NICOLE DENISE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DENISE
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4131 MARK TWAIN CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-8233
Mailing Address - Country:US
Mailing Address - Phone:725-204-7591
Mailing Address - Fax:
Practice Address - Street 1:2755 E DESERT INN RD STE 240
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3610
Practice Address - Country:US
Practice Address - Phone:725-240-7591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV02218246ZE0500X
NV0020102218EAWHC3747P1801X
NV60898-AO-0246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant