Provider Demographics
NPI:1588646665
Name:STREET, NELLADEE (FNP)
Entity Type:Individual
Prefix:PROF
First Name:NELLADEE
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BERTHA HOWE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-7502
Mailing Address - Country:US
Mailing Address - Phone:702-346-0800
Mailing Address - Fax:702-346-0801
Practice Address - Street 1:1301 BERTHA HOWE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-7502
Practice Address - Country:US
Practice Address - Phone:702-346-0800
Practice Address - Fax:702-346-0801
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN00314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ811580Medicaid