MEDICARE: SACRED HEART WELLNESS CENTER PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1992682751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED HEART WELLNESS CENTER PLLC

Provider Business Mailing Address
First Line	:	5300 W SAHARA AVE STE 201
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-0367
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 W SAHARA AVE STE 201
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-0367
Country	:	US
Telephone Number	:	774-262-9933
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	EMMANUEL TETTEH AGBOTTAH
Credential	:	APRN
Telephone Number	:	774-262-9933

Provider Enumeration Date	:	08/21/2025
Last Update Date	:	08/21/2025

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