MEDICARE: KEANNE ALYSSE PROLLAMANTE OTD, OTR/L

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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1255156782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEANNE ALYSSE PROLLAMANTE OTD, OTR/L

Provider Business Mailing Address
First Line	:	11215 GAMMILA DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-0435
Country	:	US
Telephone Number	:	702-378-6741
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 W HORIZON RIDGE PKWY STE 100
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-2707
Country	:	US
Telephone Number	:	702-458-1300
Fax Number	:

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

Provider Enumeration Date	:	11/19/2024
Last Update Date	:	11/19/2024

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