Provider Demographics
NPI:1083102131
Name:COLLETTA, KASSANDRA
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:COLLETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-405-6503
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY STE 303
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2314
Practice Address - Country:US
Practice Address - Phone:702-944-2888
Practice Address - Fax:702-944-2890
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV22581207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program