Healthcare Provider Details

I. General information

NPI: 1043801012
Provider Name (Legal Business Name): BEVERLY BATALLA THIELKE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12300 SANDY PEAK AVE
LAS VEGAS NV
89138-1116
US

IV. Provider business mailing address

3459 SAINT ROSE PKWY STE 120-481
HENDERSON NV
89052-4601
US

V. Phone/Fax

Practice location:
  • Phone: 702-606-2072
  • Fax:
Mailing address:
  • Phone: 702-781-4800
  • Fax: 702-664-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number837645
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number837645
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number837645
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: