MEDICARE: NICOLE YVONNE KILEY RD

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	133V00000X	Registered Dietitian	86017761	CA

General Provider Information

NPI Number	:	1972905792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE YVONNE KILEY RD

Provider Business Mailing Address
First Line	:	8000 BADURA AVE UNIT 2147
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-2119
Country	:	US
Telephone Number	:	714-745-9894
Fax Number	:

Provider Business Practice Location Address
First Line	:	8000 BADURA AVE UNIT 2147
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-2119
Country	:	US
Telephone Number	:	714-745-9894
Fax Number	:

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

Provider Enumeration Date	:	09/24/2014
Last Update Date	:	01/18/2017

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