Healthcare Provider Details

I. General information

NPI: 1588646665
Provider Name (Legal Business Name): NELLADEE STREET F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 BERTHA HOWE AVE SUITE 1
MESQUITE NV
89027-7502
US

IV. Provider business mailing address

1301 BERTHA HOWE AVE SUITE 1
MESQUITE NV
89027-7502
US

V. Phone/Fax

Practice location:
  • Phone: 702-346-0800
  • Fax: 702-346-0801
Mailing address:
  • Phone: 702-346-0800
  • Fax: 702-346-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPN00314
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: