Healthcare Provider Details

I. General information

NPI: 1780441998
Provider Name (Legal Business Name): IDENTITY HORMONES NV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 N GREEN VALLEY PKWY STE F
HENDERSON NV
89074-5885
US

IV. Provider business mailing address

1701 N GREEN VALLEY PKWY STE F
HENDERSON NV
89074-5885
US

V. Phone/Fax

Practice location:
  • Phone: 702-661-3438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMANDA WILKINSON
Title or Position: BUSINESS OPERATIONS DIRECTOR
Credential:
Phone: 602-796-2559