MEDICARE: KELLY VASHON LIGGONS FNP-C

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	363LF0000X	Family Nurse Practitioner	873589	NV

General Provider Information

NPI Number	:	1962279968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY VASHON LIGGONS FNP-C

Provider Business Mailing Address
First Line	:	8005 SAN MATEO ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89085-2304
Country	:	US
Telephone Number	:	317-833-5620
Fax Number	:

Provider Business Practice Location Address
First Line	:	7210 W LAKE MEAD BLVD STE 4
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-8353
Country	:	US
Telephone Number	:	702-202-4460
Fax Number	:

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

Provider Enumeration Date	:	12/08/2023
Last Update Date	:	03/07/2024

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