Healthcare Provider Details

I. General information

NPI: 1396018578
Provider Name (Legal Business Name): TIANA MARIE VERNOOY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIANA MARIE KELLOGG

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 RENAISSANCE DR SUITE A
LAS VEGAS NV
89119-6191
US

IV. Provider business mailing address

200 N PECOS RD TRLR 62
LAS VEGAS NV
89101-4867
US

V. Phone/Fax

Practice location:
  • Phone: 702-739-7716
  • Fax: 702-597-2242
Mailing address:
  • Phone: 559-355-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: