Provider Demographics
NPI:1073033528
Name:MULLISSA CHILDRESS
Entity Type:Organization
Organization Name:MULLISSA CHILDRESS
Other - Org Name:CCM MEDICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MULLISSA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CHILDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:702-406-4125
Mailing Address - Street 1:5300 BRIGHT SUN CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130
Mailing Address - Country:US
Mailing Address - Phone:702-487-7055
Mailing Address - Fax:702-991-7258
Practice Address - Street 1:222 S RAINBOW BLVD STE 115
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-5126
Practice Address - Country:US
Practice Address - Phone:702-406-4125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20161298264363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty