Healthcare Provider Details

I. General information

NPI: 1447523741
Provider Name (Legal Business Name): IDA BERNADETTE PLAZA WILL APN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8595 S DECATUR BLVD STE 108
LAS VEGAS NV
89139-7006
US

IV. Provider business mailing address

6355 S BUFFALO DR FL 3
LAS VEGAS NV
89113-2133
US

V. Phone/Fax

Practice location:
  • Phone: 702-948-1130
  • Fax: 702-688-8861
Mailing address:
  • Phone: 702-216-3346
  • Fax: 702-671-6883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP4629
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-990292
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN001592
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: