Provider Demographics
NPI:1225371891
Name:PACKER, NYLASIA
Entity Type:Individual
Prefix:
First Name:NYLASIA
Middle Name:
Last Name:PACKER
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 1:650 E AZURE AVE APT 3088
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6882
Mailing Address - Country:US
Mailing Address - Phone:702-917-9782
Mailing Address - Fax:
Practice Address - Street 1:6360 S PECOS RD
Practice Address - Street 2:SUITE 4
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3296
Practice Address - Country:US
Practice Address - Phone:702-816-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1403364680103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1403364680Medicaid