Healthcare Provider Details

I. General information

NPI: 1306419213
Provider Name (Legal Business Name): GLADYS CARBONILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 W HORIZON RIDGE PKWY STE 100
HENDERSON NV
89052-4836
US

IV. Provider business mailing address

1500 E TROPICANA AVE STE 161
LAS VEGAS NV
89119-6516
US

V. Phone/Fax

Practice location:
  • Phone: 702-360-0010
  • Fax:
Mailing address:
  • Phone: 702-462-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number878472
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: