Healthcare Provider Details

I. General information

NPI: 1528654449
Provider Name (Legal Business Name): MS. SHANNON LEE PATT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N 13TH ST
LAS VEGAS NV
89101-4156
US

IV. Provider business mailing address

4000 E BONANZA RD APT 118
LAS VEGAS NV
89110-2274
US

V. Phone/Fax

Practice location:
  • Phone: 702-384-3746
  • Fax: 702-366-0498
Mailing address:
  • Phone: 702-945-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number813784
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: