Provider Demographics
NPI:1073033528
Name:MULLISSA CHILDRESS CCM MEDICAL SERVICES
Entity type:Organization
Organization Name:MULLISSA CHILDRESS CCM MEDICAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER PROVIDER
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:614-496-8420
Mailing Address - Fax:702-745-0452
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:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty