Provider Demographics
NPI:1518796986
Name:NICOTHODES, DEZIREE NICOLE
Entity type:Individual
Prefix:
First Name:DEZIREE
Middle Name:NICOLE
Last Name:NICOTHODES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2246
Mailing Address - Country:US
Mailing Address - Phone:909-544-1676
Mailing Address - Fax:
Practice Address - Street 1:2243 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-1586
Practice Address - Country:US
Practice Address - Phone:909-544-1676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker