Healthcare Provider Details

I. General information

NPI: 1699401968
Provider Name (Legal Business Name): MCKELL KELLOGG PRINCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MCKELL KELLOGG

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 S RAINBOW BLVD STE 250
LAS VEGAS NV
89118-1807
US

IV. Provider business mailing address

3016 W CHARLESTON BLVD STE 100
LAS VEGAS NV
89102-1973
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-6480
  • Fax: 702-671-6481
Mailing address:
  • Phone: 702-780-2315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2909
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: