Healthcare Provider Details

I. General information

NPI: 1801874631
Provider Name (Legal Business Name): JOHANNA S. FRICKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 N BUFFALO DR SUITE B
LAS VEGAS NV
89145-0300
US

IV. Provider business mailing address

331 N BUFFALO DR SUITE B
LAS VEGAS NV
89145-0300
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-2520
  • Fax: 702-877-2521
Mailing address:
  • Phone: 702-877-2520
  • Fax: 702-877-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3166
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number3166
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: