Healthcare Provider Details

I. General information

NPI: 1669092367
Provider Name (Legal Business Name): STACEY LOUISE SIESE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10105 BANBURRY CROSS DR
LAS VEGAS NV
89144-6646
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-5199
  • Fax:
Mailing address:
  • Phone: 702-877-5199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number828101
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: