MEDICARE: MRS. ROSANNA R OCTAVIANO APN

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	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	APN001140	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APN001140	OTHER	NV	NURSING LICENSE

General Provider Information

NPI Number	:	1760828214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ROSANNA R OCTAVIANO APN

Provider Business Mailing Address
First Line	:	PO BOX 778207
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89077-8207
Country	:	US
Telephone Number	:	702-855-0748
Fax Number	:	702-436-8088

Provider Business Practice Location Address
First Line	:	3680 E SUNSET RD
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-7235
Country	:	US
Telephone Number	:	702-855-0748
Fax Number	:	702-436-8088

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

Provider Enumeration Date	:	05/10/2013
Last Update Date	:	10/25/2013

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