Provider Demographics
NPI:1619429933
Name:GRADY, LILNETRA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LILNETRA
Middle Name:
Last Name:GRADY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8936 SPANISH RIDGE AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1354
Mailing Address - Country:US
Mailing Address - Phone:702-998-2816
Mailing Address - Fax:702-998-2991
Practice Address - Street 1:400 SHADOW LN STE 106
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4355
Practice Address - Country:US
Practice Address - Phone:702-731-0909
Practice Address - Fax:702-826-4767
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015079363LF0000X
NV813525363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1619429933Medicaid