Healthcare Provider Details

I. General information

NPI: 1235664020
Provider Name (Legal Business Name): BETTY OMANDAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 FIRE MESA ST SUITE 160
LAS VEGAS NV
89128-9016
US

IV. Provider business mailing address

2440 PROFESSIONAL CT STE 110
LAS VEGAS NV
89128-0839
US

V. Phone/Fax

Practice location:
  • Phone: 702-518-1534
  • Fax:
Mailing address:
  • Phone: 702-518-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN 002508
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: