MEDICARE: VIRGINIA LEE PRATT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	NV20161363095	NV

General Provider Information

NPI Number	:	1093249922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRGINIA LEE PRATT

Provider Business Mailing Address
First Line	:	777 QUARTZ AVENUE
Second Line	:	PMB 7714
City	:	SAMDY VALLEY
State	:	NV
Zip	:	89019
Country	:	US
Telephone Number	:	702-305-9475
Fax Number	:

Provider Business Practice Location Address
First Line	:	2424 POLONA ST
Second Line	:
City	:	SANDY VALLEY
State	:	NV
Zip	:	89019-1769
Country	:	US
Telephone Number	:	702-305-9475
Fax Number	:

Authorized Official
Title or Position	:	OWMER
Name	:	MS. VIRGINIA LEE PRATT
Credential	:
Telephone Number	:	702-375-0294

Provider Enumeration Date	:	04/18/2017
Last Update Date	:	04/18/2017

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