MEDICARE: MA MARIANE GONDRANEOS REYES APRN

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	868153	NV

General Provider Information

NPI Number	:	1902580871
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MA MARIANE GONDRANEOS REYES APRN

Provider Business Mailing Address
First Line	:	3545 S FORT APACHE RD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-3441
Country	:	US
Telephone Number	:	702-553-1643
Fax Number	:

Provider Business Practice Location Address
First Line	:	3545 S FORT APACHE RD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-3441
Country	:	US
Telephone Number	:	702-553-1643
Fax Number	:	702-718-7991

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

Provider Enumeration Date	:	06/12/2023
Last Update Date	:	04/01/2025

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