=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619851953
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ROSE DIANA KUAN DE LA CRUZ APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2025
-----------------------------------------------------
Last Update Date | 07/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8905 W POST RD STE 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-927-6866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 432 EASTGATE LN
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-4191
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-927-6866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 891144
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 891144
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------