Provider Demographics
NPI:1467231506
Name:NISHIDA-COSTELLO, LIANNE SHIZUE (CHW)
Entity Type:Individual
Prefix:
First Name:LIANNE
Middle Name:SHIZUE
Last Name:NISHIDA-COSTELLO
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:LIANNE
Other - Middle Name:SHIZUE
Other - Last Name:NISHIDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8936 SPANISH RIDGE AVENUE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148
Mailing Address - Country:US
Mailing Address - Phone:702-731-0909
Mailing Address - Fax:702-998-2991
Practice Address - Street 1:400 SHADOW LANE
Practice Address - Street 2:SUITE 104
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106
Practice Address - Country:US
Practice Address - Phone:702-731-0909
Practice Address - Fax:702-826-4757
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCHWI-5446172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker