Healthcare Provider Details

I. General information

NPI: 1053778290
Provider Name (Legal Business Name): ANDREA DIANE PALACIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 MARLBERRY PL
HENDERSON NV
89015-7475
US

IV. Provider business mailing address

675 MARLBERRY PL
HENDERSON NV
89015-7475
US

V. Phone/Fax

Practice location:
  • Phone: 702-626-6973
  • Fax:
Mailing address:
  • Phone: 702-626-6973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA017438
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: