Healthcare Provider Details

I. General information

NPI: 1992894018
Provider Name (Legal Business Name): RUTH ELLEN HANSON MSN, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/09/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99TH MDG HCOS, SGOC-PEDIATRIC CLINIC 4700 LAS VEGAS BLVD. N.
NELLIS AFB NV
89191
US

IV. Provider business mailing address

99TH MDG HCOS, SGOC-PEDIATRIC CLINIC 4700 LAS VEGAS BLVD. N.
NELLIS AFB NV
89191
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-3504
  • Fax:
Mailing address:
  • Phone: 702-653-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number13-41410-092
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: