Healthcare Provider Details

I. General information

NPI: 1669117701
Provider Name (Legal Business Name): GISELLE LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 W CHARLESTON BLVD
LAS VEGAS NV
89102-1944
US

IV. Provider business mailing address

9713 AMBER PEAK CT
LAS VEGAS NV
89144-0806
US

V. Phone/Fax

Practice location:
  • Phone: 702-477-0707
  • Fax:
Mailing address:
  • Phone: 702-232-5055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number810107
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: