Provider Demographics
NPI:1417590316
Name:ANDERSON, NICOLE A (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8906 SPANISH RIDGE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1319
Mailing Address - Country:US
Mailing Address - Phone:702-330-3102
Mailing Address - Fax:702-912-4994
Practice Address - Street 1:5320 S RAINBOW BLVD STE 282
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1896
Practice Address - Country:US
Practice Address - Phone:702-243-0202
Practice Address - Fax:702-262-9330
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV819198363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250004905Medicaid