Provider Demographics
NPI:1689320137
Name:UDALVE, ROWELL (FNP-C)
Entity Type:Individual
Prefix:
First Name:ROWELL
Middle Name:
Last Name:UDALVE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S PARK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8541
Mailing Address - Country:US
Mailing Address - Phone:954-923-7440
Mailing Address - Fax:954-923-1299
Practice Address - Street 1:6240 N DURANGO DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3941
Practice Address - Country:US
Practice Address - Phone:954-923-7440
Practice Address - Fax:954-923-1299
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVF12210389363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250018501Medicaid