Healthcare Provider Details

I. General information

NPI: 1669187670
Provider Name (Legal Business Name): PERSIA THE PSYCH NP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/16/2023
Certification Date: 01/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 S FORT APACHE RD
LAS VEGAS NV
89148-7700
US

IV. Provider business mailing address

5510 S FORT APACHE RD
LAS VEGAS NV
89148-7700
US

V. Phone/Fax

Practice location:
  • Phone: 702-848-5520
  • Fax:
Mailing address:
  • Phone: 702-848-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PERSIA COLEMAN
Title or Position: OWNER
Credential: APRN
Phone: 702-848-5520