MEDICARE: RENNETTE TIAMSON BULATAO NURSE PRACTITIONER

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	363LG0600X	Gerontology Nurse Practitioner	815814	NV
2	363LF0000X	Family Nurse Practitioner	815814	NV

General Provider Information

NPI Number	:	1285364877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENNETTE TIAMSON BULATAO NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	PO BOX 35380
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-5380
Country	:	US
Telephone Number	:	760-708-5463
Fax Number	:

Provider Business Practice Location Address
First Line	:	4475 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7826
Country	:	US
Telephone Number	:	702-877-5119
Fax Number	:

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

Provider Enumeration Date	:	06/15/2022
Last Update Date	:	04/09/2026

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Directions to “ RENNETTE TIAMSON BULATAO NURSE PRACTITIONER” Practice Location

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