Provider Demographics
NPI:1831679760
Name:MACIAS, CONSUELO
Entity Type:Individual
Prefix:
First Name:CONSUELO
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 INDIAN RIVER DR UNIT 241
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-7438
Mailing Address - Country:US
Mailing Address - Phone:702-720-8935
Mailing Address - Fax:
Practice Address - Street 1:5320 INDIAN RIVER DR UNIT 241
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-7438
Practice Address - Country:US
Practice Address - Phone:702-720-8935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ$$$$$$$$$Medicaid