Healthcare Provider Details

I. General information

NPI: 1205021474
Provider Name (Legal Business Name): MINNIE ELIZABETH WOOD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MINNIE ELIZABETH CANCELLARO

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S 4TH ST STE 111
LAS VEGAS NV
89104-1046
US

IV. Provider business mailing address

1200 S 4TH ST STE 111
LAS VEGAS NV
89104-1046
US

V. Phone/Fax

Practice location:
  • Phone: 702-380-8118
  • Fax: 702-380-2929
Mailing address:
  • Phone: 702-380-8118
  • Fax: 702-380-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number661205
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17447
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberAPRN001647
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: