Healthcare Provider Details

I. General information

NPI: 1669944484
Provider Name (Legal Business Name): HOME PROFESSIONAL NURSE PRACTITIONER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 W CHARLESTON BLVD STE 70
LAS VEGAS NV
89102-1928
US

IV. Provider business mailing address

3017 W CHARLESTON BLVD STE 70
LAS VEGAS NV
89102-1928
US

V. Phone/Fax

Practice location:
  • Phone: 702-913-9380
  • Fax:
Mailing address:
  • Phone: 702-913-9380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. MAE DEREQUITO LUECK
Title or Position: CEO
Credential:
Phone: 702-913-9380