Healthcare Provider Details

I. General information

NPI: 1629990130
Provider Name (Legal Business Name): SHANTALLE BELEN JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7365 PRAIRIE FALCON RD STE 110
LAS VEGAS NV
89128-0808
US

IV. Provider business mailing address

11848 ORENSE DR
LAS VEGAS NV
89138-4563
US

V. Phone/Fax

Practice location:
  • Phone: 702-462-5252
  • Fax:
Mailing address:
  • Phone: 830-391-5956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-4601
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: