Provider Demographics
NPI:1376083394
Name:VERGARA, ANTONETTE (APRN)
Entity Type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:
Last Name:VERGARA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 W CHARLESTON BLVD # 150
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1998
Mailing Address - Country:US
Mailing Address - Phone:702-476-9999
Mailing Address - Fax:
Practice Address - Street 1:1569 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5321
Practice Address - Country:US
Practice Address - Phone:702-476-9999
Practice Address - Fax:702-946-1343
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002468363L00000X, 163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0000XNursing Service ProvidersRegistered NursePain Management
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner