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General NPI Number Information
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NPI Number | 1164055919
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Entity Type | Individual
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Provider Name | SHANAE EBONY GLASS
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Gender | Female
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Dates
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Enumeration Date | 02/20/2020
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Last Update Date | 02/20/2020
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Provider Practice Location Address
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Address Line | 2580 NORTH RANCHO SUITE 105-106
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City | NORTH LAS VEGAS
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State | NV
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Zip | 89032
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Country | US
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Telephone | 702-475-4175
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Fax |
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Provider Business Mailing Address
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Address Line | 4361 APONTE ST APT 203
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City | LAS VEGAS
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State | NV
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Zip | 89115-1632
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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