Healthcare Provider Details

I. General information

NPI: 1831067032
Provider Name (Legal Business Name): YSHMAELLE KIM LOIS LA ROSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 LUCKY PINE ST
HENDERSON NV
89002-3300
US

IV. Provider business mailing address

678 LUCKY PINE ST
HENDERSON NV
89002-3300
US

V. Phone/Fax

Practice location:
  • Phone: 702-906-6411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number894026
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: