Healthcare Provider Details

I. General information

NPI: 1063165223
Provider Name (Legal Business Name): BRONWYN KATIE CHANEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 01/28/2022
Certification Date: 12/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 S RAINBOW BLVD STE 131
LAS VEGAS NV
89146-6208
US

IV. Provider business mailing address

3311 S RAINBOW BLVD STE 131
LAS VEGAS NV
89146-6208
US

V. Phone/Fax

Practice location:
  • Phone: 702-368-6880
  • Fax: 702-213-9042
Mailing address:
  • Phone: 702-368-6880
  • Fax: 702-213-9042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number10204-PCS-0
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: