Healthcare Provider Details

I. General information

NPI: 1720097363
Provider Name (Legal Business Name): NORMA JEAN THIEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 S JONES BLVD
LAS VEGAS NV
89103-2456
US

IV. Provider business mailing address

P.O. BOX 360001
NORTH LAS VEGAS NV
89036-8108
US

V. Phone/Fax

Practice location:
  • Phone: 702-636-3000
  • Fax: 702-636-6369
Mailing address:
  • Phone: 702-636-3000
  • Fax: 702-636-6369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number810373
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: