Provider Demographics
NPI:1861026403
Name:MAYFIELD, ROSHONDA JANEANE
Entity Type:Individual
Prefix:
First Name:ROSHONDA
Middle Name:JANEANE
Last Name:MAYFIELD
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:PO BOX 572237
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89157-2237
Mailing Address - Country:US
Mailing Address - Phone:702-808-2656
Mailing Address - Fax:702-478-6932
Practice Address - Street 1:2675 NORTH DECATUR BOULEVARD
Practice Address - Street 2:#572237
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-8910
Practice Address - Country:US
Practice Address - Phone:702-808-2565
Practice Address - Fax:702-478-6932
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-22
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20212085386253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20212085386Medicaid