Provider Demographics
NPI:1699401968
Name:PRINCE, MCKELL KELLOGG
Entity Type:Individual
Prefix:
First Name:MCKELL
Middle Name:KELLOGG
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MCKELL
Other - Middle Name:
Other - Last Name:KELLOGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-780-2315
Mailing Address - Fax:
Practice Address - Street 1:5320 S RAINBOW BLVD STE 250
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1807
Practice Address - Country:US
Practice Address - Phone:702-671-6480
Practice Address - Fax:702-671-6481
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVPA2909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program