MEDICARE: GRACE CADAVONA

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	163W00000X	Registered Nurse	RN75368	NV
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	842734	NV

General Provider Information

NPI Number	:	1538670310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE CADAVONA

Provider Business Mailing Address
First Line	:	6438 ELIZABETHTOWN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-2868
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5580 W FLAMINGO RD STE 107
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-0165
Country	:	US
Telephone Number	:	702-997-4455
Fax Number	:

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

Provider Enumeration Date	:	10/19/2017
Last Update Date	:	02/22/2022

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Directions to “ GRACE CADAVONA ” Practice Location

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