Healthcare Provider Details

I. General information

NPI: 1164559415
Provider Name (Legal Business Name): JEANIE MARIE KITTLESON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST ROSE DOMINICAN DE LIMA 102 E LAKE MEAD PKWY
HENDERSON NV
89015
US

IV. Provider business mailing address

237 HANLEY WAY
HENDERSON NV
89074-5387
US

V. Phone/Fax

Practice location:
  • Phone: 702-616-4600
  • Fax: 702-616-4311
Mailing address:
  • Phone: 252-258-2164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA833
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA833
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9114559
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA833
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: