Healthcare Provider Details

I. General information

NPI: 1619003928
Provider Name (Legal Business Name): KIM GENET MOFFATT-BAZILE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 S. MARYLAND PKWY SUITE 220
LAS VEGAS NV
89109
US

IV. Provider business mailing address

747 52ND ST HEMO/ONCOLOGY DEPT
OAKLAND CA
94609-1809
US

V. Phone/Fax

Practice location:
  • Phone: 702-732-1493
  • Fax: 702-732-1080
Mailing address:
  • Phone: 510-428-3372
  • Fax: 510-597-7199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN80724
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8485
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberAPRN001811
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: