Healthcare Provider Details

I. General information

NPI: 1366720633
Provider Name (Legal Business Name): DANA S WIDDISON M.S.N, A.P.N., C.N.M
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SHADOW LANE SUITE 165-A
LAS VEGAS NV
89106
US

IV. Provider business mailing address

700 SHADOW LANE SUITE 165-A
LAS VEGAS NV
89106
US

V. Phone/Fax

Practice location:
  • Phone: 702-522-9640
  • Fax: 702-522-9641
Mailing address:
  • Phone: 702-522-9640
  • Fax: 702-522-9641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN15770
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAPN00207
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: