Healthcare Provider Details

I. General information

NPI: 1407651219
Provider Name (Legal Business Name): JERRY ANN BALBOA GUMABON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 06/14/2025
Certification Date: 06/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5216 BOULDER HWY
LAS VEGAS NV
89122-6074
US

IV. Provider business mailing address

5216 BOULDER HWY
LAS VEGAS NV
89122-6074
US

V. Phone/Fax

Practice location:
  • Phone: 702-547-6764
  • Fax:
Mailing address:
  • Phone: 702-547-6764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number824950
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: