Healthcare Provider Details

I. General information

NPI: 1497625685
Provider Name (Legal Business Name): PRADEEPTA MAMIDI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N TENAYA WAY
LAS VEGAS NV
89128-0482
US

IV. Provider business mailing address

3010 VILLA MARBELLA CIR
RENO NV
89509-6600
US

V. Phone/Fax

Practice location:
  • Phone: 832-869-4818
  • Fax:
Mailing address:
  • Phone: 701-978-5147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number868672
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: