Healthcare Provider Details

I. General information

NPI: 1144252826
Provider Name (Legal Business Name): MARY ELLEN GAUTHIER APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 S. MARYLAND PKWY
LAS VEGAS NV
89154-3020
US

IV. Provider business mailing address

888 W BONNEVILLE AVE
LAS VEGAS NV
89106-0100
US

V. Phone/Fax

Practice location:
  • Phone: 702-895-0540
  • Fax: 702-895-4316
Mailing address:
  • Phone: 702-483-6000
  • Fax: 702-483-6039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN00508
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: