Provider Demographics
NPI:1932872595
Name:MCDERMOTT, LUCILLE VINCENT
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:VINCENT
Last Name:MCDERMOTT
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 1:121 CALLE DEL PRESIDENTE
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-6091
Mailing Address - Country:US
Mailing Address - Phone:505-238-9778
Mailing Address - Fax:
Practice Address - Street 1:121 CALLE DEL PRESIDENTE
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-6091
Practice Address - Country:US
Practice Address - Phone:505-867-2324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM64100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily