Provider Demographics
NPI:1669500120
Name:STALL, THERESA B (ARNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:B
Last Name:STALL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:BAUTISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:7050 SMOKE RANCH RD
Mailing Address - Street 2:STE 130
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-8609
Mailing Address - Country:US
Mailing Address - Phone:702-233-9911
Mailing Address - Fax:702-243-5568
Practice Address - Street 1:7050 SMOKE RANCH RD
Practice Address - Street 2:STE 130
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-8609
Practice Address - Country:US
Practice Address - Phone:702-233-9911
Practice Address - Fax:702-243-5568
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007643363LA2100X
DC1007373363LA2100X
NVAPN001380363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0219957OtherL&I
WA9652496Medicaid
WA03851UOtherREGENCE BLUE SHIELD
DC161687YT2Medicare PIN
WA03851UOtherREGENCE BLUE SHIELD