=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528520640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYNISHA BERNEE RICHARDSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2019
-----------------------------------------------------
Last Update Date | 05/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 616 VICTORIAN AVE
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-203-2783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 616 VICTORIAN AVE
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89431-5024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-203-2783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number | C-35679
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------