Healthcare Provider Details

I. General information

NPI: 1336858364
Provider Name (Legal Business Name): ELLEN EVERSOLE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 W SUNSET RD STE 120
HENDERSON NV
89014-6635
US

IV. Provider business mailing address

2680 PARISIANS CT
HENDERSON NV
89044-2003
US

V. Phone/Fax

Practice location:
  • Phone: 855-955-5428
  • Fax: 844-389-0835
Mailing address:
  • Phone: 702-456-9512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF09200362
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: