Provider Demographics
NPI:1851867295
Name:KNAACK, VIRGINIA ALICA (PCA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:ALICA
Last Name:KNAACK
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 FULSTONE WAY APT 1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-6642
Mailing Address - Country:US
Mailing Address - Phone:702-504-2473
Mailing Address - Fax:
Practice Address - Street 1:6950 KEPLER DR APT A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-6096
Practice Address - Country:US
Practice Address - Phone:310-406-5211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant