Provider Demographics
NPI:1083181481
Name:BURCHETT, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:BURCHETT
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 1:3940 SCOTT ROBINSON BLVD APT 1132
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-7877
Mailing Address - Country:US
Mailing Address - Phone:702-355-6555
Mailing Address - Fax:
Practice Address - Street 1:3940 SCOTT ROBINSON BLVD APT 1132
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-7877
Practice Address - Country:US
Practice Address - Phone:702-355-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00001255081Medicaid