Healthcare Provider Details

I. General information

NPI: 1265261218
Provider Name (Legal Business Name): KELLY DANIELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 09/07/2024
Certification Date: 09/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 W AZURE DR STE 140
LAS VEGAS NV
89130-4425
US

IV. Provider business mailing address

9344 BRIGHT BLUE SKY AVE
LAS VEGAS NV
89166-3787
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-4047
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: