Provider Demographics
NPI:1043569700
Name:FRAZIER, TARESA LAVONNE (LPN)
Entity Type:Individual
Prefix:
First Name:TARESA
Middle Name:LAVONNE
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TARESA
Other - Middle Name:LAVONNE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6156 STONE HOLLOW AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-4797
Mailing Address - Country:US
Mailing Address - Phone:702-606-1247
Mailing Address - Fax:
Practice Address - Street 1:6156 STONE HOLLOW AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-4797
Practice Address - Country:US
Practice Address - Phone:702-606-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-09
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner