Provider Demographics
NPI:1073714705
Name:CROSS, ANGELIQUE J (NP-C)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:J
Last Name:CROSS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 ADAMS BLVD
Mailing Address - Street 2:
Mailing Address - City:BOULDER CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89005-2213
Mailing Address - Country:US
Mailing Address - Phone:702-698-8342
Mailing Address - Fax:702-293-0430
Practice Address - Street 1:999 ADAMS BLVD STE 104-105
Practice Address - Street 2:
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-2244
Practice Address - Country:US
Practice Address - Phone:702-698-8342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006597363L00000X
NVAPRN001727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1073714705Medicaid
NV1073714705Medicaid
ILP00730516Medicare PIN