Healthcare Provider Details

I. General information

NPI: 1760257075
Provider Name (Legal Business Name): SAMANTHA NICOLE DIEGUEZ-LORENZANA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6345 S JONES BLVD
LAS VEGAS NV
89118-3333
US

IV. Provider business mailing address

3093 GREENBRIAR DR
LAS VEGAS NV
89121-2405
US

V. Phone/Fax

Practice location:
  • Phone: 702-515-4009
  • Fax:
Mailing address:
  • Phone: 702-913-8398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1632
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: