MEDICARE: MARY ANN BENOGSUDAN TIPANERO

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	878735	NV

General Provider Information

NPI Number	:	1497504666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ANN BENOGSUDAN TIPANERO

Provider Business Mailing Address
First Line	:	5806 STEINBECK VALLEY ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-0794
Country	:	US
Telephone Number	:	701-818-0655
Fax Number	:

Provider Business Practice Location Address
First Line	:	5806 STEINBECK VALLEY ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-0794
Country	:	US
Telephone Number	:	701-818-0655
Fax Number	:

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

Provider Enumeration Date	:	05/17/2024
Last Update Date	:	05/17/2024

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