Healthcare Provider Details

I. General information

NPI: 1942034566
Provider Name (Legal Business Name): TASHA GRADY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 HOWARD HUGHES PKWY STE 300
LAS VEGAS NV
89169-0946
US

IV. Provider business mailing address

11823 S BISHOP ST
CHICAGO IL
60643-5013
US

V. Phone/Fax

Practice location:
  • Phone: 702-560-2192
  • Fax:
Mailing address:
  • Phone: 773-216-3353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number877658
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: