MEDICARE: GRENY MALIAKAL APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	APRN002667	NV

General Provider Information

NPI Number	:	1033625330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRENY MALIAKAL APRN

Provider Business Mailing Address
First Line	:	1450 W HORIZON RIDGE PKWY
Second Line	:	B304 #668
City	:	HENDERSON
State	:	NV
Zip	:	89012-4477
Country	:	US
Telephone Number	:	702-868-8387
Fax Number	:	702-314-9134

Provider Business Practice Location Address
First Line	:	6088 S DURANGO DR STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-1780
Country	:	US
Telephone Number	:	702-380-4242
Fax Number	:	702-380-4141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2017
Last Update Date	:	12/21/2017

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