MEDICARE: MARY ELLEN GAUTHIER APRN-BC

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	363LF0000X	Family Nurse Practitioner	APN00508	NV

General Provider Information

NPI Number	:	1144252826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ELLEN GAUTHIER APRN-BC

Provider Business Mailing Address
First Line	:	888 W BONNEVILLE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-0100
Country	:	US
Telephone Number	:	702-483-6000
Fax Number	:	702-483-6039

Provider Business Practice Location Address
First Line	:	4505 S. MARYLAND PKWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89154-3020
Country	:	US
Telephone Number	:	702-895-0540
Fax Number	:	702-895-4316

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	04/15/2022

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