Healthcare Provider Details

I. General information

NPI: 1629621123
Provider Name (Legal Business Name): GRETEL CANCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 S MARYLAND PKWY APT L101
LAS VEGAS NV
89109-1574
US

IV. Provider business mailing address

2850 S MARYLAND PKWY APT L101
LAS VEGAS NV
89109-1574
US

V. Phone/Fax

Practice location:
  • Phone: 702-727-9685
  • Fax:
Mailing address:
  • Phone: 702-727-9685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPT18997
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: