MEDICARE: MS. BANNELLY AYLIN GASPAR URBINA

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	106S00000X	Behavior Technician		NV

General Provider Information

NPI Number	:	1811590995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BANNELLY AYLIN GASPAR URBINA

Provider Business Mailing Address
First Line	:	7227 W WINDMILL LN UNIT 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-4605
Country	:	US
Telephone Number	:	858-285-5573
Fax Number	:

Provider Business Practice Location Address
First Line	:	7227 W WINDMILL LN UNIT 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-4605
Country	:	US
Telephone Number	:	858-285-5573
Fax Number	:

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

Provider Enumeration Date	:	11/19/2020
Last Update Date	:	06/06/2023

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