MEDICARE: KELLI NISSEN

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	363LG0600X	Gerontology Nurse Practitioner	867835	NV

General Provider Information

NPI Number	:	1952093692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI NISSEN

Provider Business Mailing Address
First Line	:	2031 MCDANIEL ST STE 200
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-6312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2031 MCDANIEL ST STE 200
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-6312
Country	:	US
Telephone Number	:	702-294-0080
Fax Number	:

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

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	05/02/2024

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Directions to “ KELLI NISSEN ” Practice Location

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