Healthcare Provider Details

I. General information

NPI: 1093249922
Provider Name (Legal Business Name): VIRGINIA LEE PRATT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 POLONA ST
SANDY VALLEY NV
89019-1769
US

IV. Provider business mailing address

777 QUARTZ AVENUE PMB 7714
SAMDY VALLEY NV
89019
US

V. Phone/Fax

Practice location:
  • Phone: 702-305-9475
  • Fax:
Mailing address:
  • Phone: 702-305-9475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberNV20161363095
License Number StateNV

VIII. Authorized Official

Name: MS. VIRGINIA LEE PRATT
Title or Position: OWMER
Credential:
Phone: 702-375-0294