Healthcare Provider Details

I. General information

NPI: 1609761261
Provider Name (Legal Business Name): TATIANA SOFRONOVA GRZEDA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 S JONES BLVD STE 101
LAS VEGAS NV
89146-5632
US

IV. Provider business mailing address

2775 S JONES BLVD
LAS VEGAS NV
89146-5631
US

V. Phone/Fax

Practice location:
  • Phone: 702-685-3300
  • Fax:
Mailing address:
  • Phone: 702-685-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number831675
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: