Healthcare Provider Details

I. General information

NPI: 1992186290
Provider Name (Legal Business Name): MELISSA RENEE SOUTH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9552 WOODEN PIER WAY
LAS VEGAS NV
89117-0274
US

IV. Provider business mailing address

9552 WOODEN PIER WAY
LAS VEGAS NV
89117-0274
US

V. Phone/Fax

Practice location:
  • Phone: 702-493-4992
  • Fax:
Mailing address:
  • Phone: 702-493-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN64641
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: