Healthcare Provider Details

I. General information

NPI: 1093115461
Provider Name (Legal Business Name): TICEY RENE HARRIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3186 S MARYLAND PKWY
LAS VEGAS NV
89109-2317
US

IV. Provider business mailing address

3186 S MARYLAND PKWY
LAS VEGAS NV
89109-2317
US

V. Phone/Fax

Practice location:
  • Phone: 702-961-5000
  • Fax:
Mailing address:
  • Phone: 702-961-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN001849
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: