MEDICARE: STACEY LOUISE SIESE NP

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	363L00000X	Nurse Practitioner	828101	NV

General Provider Information

NPI Number	:	1669092367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY LOUISE SIESE NP

Provider Business Mailing Address
First Line	:	845 W CRAIG RD STE 104
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-0282
Country	:	US
Telephone Number	:	702-740-0648
Fax Number	:

Provider Business Practice Location Address
First Line	:	845 W CRAIG RD STE 104
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-0282
Country	:	US
Telephone Number	:	702-740-0648
Fax Number	:

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

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	03/01/2022

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