Provider Demographics
NPI:1821392671
Name:DE GUZMAN, NICOLLE
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:
Last Name:DE GUZMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLLE
Other - Middle Name:FERNANDEZ
Other - Last Name:DE GUZMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1031 NEVADA HWY
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-1815
Mailing Address - Country:US
Mailing Address - Phone:702-293-6347
Mailing Address - Fax:
Practice Address - Street 1:1031 NEVADA HWY
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-1815
Practice Address - Country:US
Practice Address - Phone:702-293-6347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist