Provider Demographics
NPI:1235664020
Name:OMANDAC, BETTY
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:OMANDAC
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 1:2440 PROFESSIONAL CT
Mailing Address - Street 2:STE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0839
Mailing Address - Country:US
Mailing Address - Phone:702-518-1534
Mailing Address - Fax:
Practice Address - Street 1:2410 FIRE MESA ST
Practice Address - Street 2:SUITE 160
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9016
Practice Address - Country:US
Practice Address - Phone:702-518-1534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN 002508363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology