Provider Demographics
NPI:1013372663
Name:NICHOLS, DEANDRE
Entity Type:Individual
Prefix:
First Name:DEANDRE
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 W ROME BLVD
Mailing Address - Street 2:APT #2014
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-5497
Mailing Address - Country:US
Mailing Address - Phone:323-649-7196
Mailing Address - Fax:
Practice Address - Street 1:3755 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-4897
Practice Address - Country:US
Practice Address - Phone:702-487-5665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner