=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871294447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARJORY FREDERIC PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2023
-----------------------------------------------------
Last Update Date | 05/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5940 S RAINBOW BLVD STE 400
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-854-6853
-----------------------------------------------------
Fax | 702-758-7315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5940 S RAINBOW BLVD STE 400
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-854-6853
-----------------------------------------------------
Fax | 702-758-7315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0400X
-----------------------------------------------------
Taxonomy Name | Case Management Registered Nurse
-----------------------------------------------------
License Number | RN78446
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95032219
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 871409
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------