MEDICARE: TIANA DALERECA HUBBARD ANP

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	363LA2200X	Adult Health Nurse Practitioner	APRN002430	NV
2	363LA2200X	Adult Health Nurse Practitioner	2010027053	MO

General Provider Information

NPI Number	:	1518273317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIANA DALERECA HUBBARD ANP

Provider Business Mailing Address
First Line	:	3450 W CHEYENNE AVE
Second Line	:	STE 200
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8223
Country	:	US
Telephone Number	:	314-406-9081
Fax Number	:	702-789-0717

Provider Business Practice Location Address
First Line	:	3450 W CHEYENNE AVE
Second Line	:	STE 200
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8223
Country	:	US
Telephone Number	:	314-406-9081
Fax Number	:	702-789-0717

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	03/22/2019

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