MEDICARE: MEREDITH NETTLES D'AGOSTINO DNP, PMHNP, CPNP

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	363LP0200X	Pediatric Nurse Practitioner	3584	SC
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3584	SC
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	816203	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3584-APRN	OTHER	SC	MEDICAL LICENSE
3	816203	OTHER	NV	NV APRN LICENSE

General Provider Information

NPI Number	:	1871752303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEREDITH NETTLES D'AGOSTINO DNP, PMHNP, CPNP

Provider Business Mailing Address
First Line	:	500 N RAINBOW BLVD STE 300-345
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-1082
Country	:	US
Telephone Number	:	833-246-8353
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 N RAINBOW BLVD STE 300-345
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-1082
Country	:	US
Telephone Number	:	833-246-8353
Fax Number	:	844-750-6902

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

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	09/08/2020

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