MEDICARE: ANGELICA KARINA BALISTRERI RDN

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	133V00000X	Registered Dietitian	39876-DI-2	NV

General Provider Information

NPI Number	:	1205534906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELICA KARINA BALISTRERI RDN

Provider Business Mailing Address
First Line	:	8250 N GRAND CANYON DR UNIT 2155
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-3735
Country	:	US
Telephone Number	:	702-858-0495
Fax Number	:

Provider Business Practice Location Address
First Line	:	8250 N GRAND CANYON DR UNIT 2155
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-3735
Country	:	US
Telephone Number	:	702-858-0495
Fax Number	:

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

Provider Enumeration Date	:	02/21/2023
Last Update Date	:	06/06/2025

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