=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578145033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENESSIA MARIE MELLITI APRN-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2021
-----------------------------------------------------
Last Update Date | 05/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3041 E FLAMINGO RD STE A
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89121-7447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-473-6058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10932 POSITANO ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89141-3900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-389-1267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 810968
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------