Healthcare Provider Details

I. General information

NPI: 1023964657
Provider Name (Legal Business Name): FORMA INTEGRATED HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 S RAINBOW BLVD STE 410
LAS VEGAS NV
89146-5100
US

IV. Provider business mailing address

2655 S RAINBOW BLVD STE 410
LAS VEGAS NV
89146-5100
US

V. Phone/Fax

Practice location:
  • Phone: 702-726-9722
  • Fax: 702-906-0067
Mailing address:
  • Phone: 702-726-9722
  • Fax: 702-906-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANN UGANIZA
Title or Position: CEO
Credential:
Phone: 702-531-4540