Healthcare Provider Details

I. General information

NPI: 1811296585
Provider Name (Legal Business Name): KRISHANTHI JAYATHILAKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 W HORIZON RIDGE PKWY STE 130
HENDERSON NV
89052-2731
US

IV. Provider business mailing address

2440 W HORIZON RIDGE PKWY STE 130
HENDERSON NV
89052-2731
US

V. Phone/Fax

Practice location:
  • Phone: 702-881-8191
  • Fax:
Mailing address:
  • Phone: 702-881-8191
  • Fax: 959-207-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15400
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number15400
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: