Healthcare Provider Details

I. General information

NPI: 1871294447
Provider Name (Legal Business Name): MARJORY FREDERIC PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 05/24/2025
Certification Date: 05/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5940 S RAINBOW BLVD STE 400
LAS VEGAS NV
89118-2507
US

IV. Provider business mailing address

5940 S RAINBOW BLVD STE 400
LAS VEGAS NV
89118-2507
US

V. Phone/Fax

Practice location:
  • Phone: 702-854-6853
  • Fax: 702-758-7315
Mailing address:
  • Phone: 702-854-6853
  • Fax: 702-758-7315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN78446
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95032219
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number871409
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: