Healthcare Provider Details

I. General information

NPI: 1386152148
Provider Name (Legal Business Name): KENISHA RENEA TAPIA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date: 04/04/2022
Reactivation Date: 05/02/2022

III. Provider practice location address

9260 W SUNSET RD STE 110
LAS VEGAS NV
89148-4903
US

IV. Provider business mailing address

9260 W SUNSET RD STE 110
LAS VEGAS NV
89148-4903
US

V. Phone/Fax

Practice location:
  • Phone: 702-916-6906
  • Fax:
Mailing address:
  • Phone: 702-916-6906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00004275
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: