Healthcare Provider Details

I. General information

NPI: 1255676961
Provider Name (Legal Business Name): GRAYCE LEE MALAVASIC CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10561 JEFFREYS ST STE 230
HENDERSON NV
89052-4266
US

IV. Provider business mailing address

10561 JEFFREYS ST STE 230
HENDERSON NV
89052-4266
US

V. Phone/Fax

Practice location:
  • Phone: 702-565-6565
  • Fax:
Mailing address:
  • Phone: 702-565-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number796781
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: