Healthcare Provider Details

I. General information

NPI: 1124456033
Provider Name (Legal Business Name): WINNIE WEGNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E CHARLESTON BLVD STE #130
LAS VEGAS NV
89104-6659
US

IV. Provider business mailing address

835 ROYAL MOON AVE
LAS VEGAS NV
89123-0967
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-4000
  • Fax: 702-968-4040
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN72254
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: