Healthcare Provider Details

I. General information

NPI: 1013765262
Provider Name (Legal Business Name): ALISSA FULLER SIDEBOTTOM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PILOT RD STE 250
LAS VEGAS NV
89119-3514
US

IV. Provider business mailing address

730 OAKMONT AVE UNIT 909
LAS VEGAS NV
89109-0109
US

V. Phone/Fax

Practice location:
  • Phone: 702-982-3292
  • Fax: 702-982-5286
Mailing address:
  • Phone: 951-216-4654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number866517
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: