Provider Demographics
NPI:1114153525
Name:TACK, SHEILA E (APN)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:E
Last Name:TACK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-921-2419
Practice Address - Street 1:5320 S RAINBOW BLVD STE 182
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1896
Practice Address - Country:US
Practice Address - Phone:702-255-3547
Practice Address - Fax:702-212-4993
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001125363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVGM568YMedicare PIN