Provider Demographics
NPI:1902377229
Name:CREQUE, JENIFFER (APRN)
Entity Type:Individual
Prefix:
First Name:JENIFFER
Middle Name:
Last Name:CREQUE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 S FORT APACHE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5613
Mailing Address - Country:US
Mailing Address - Phone:702-476-4900
Mailing Address - Fax:702-476-4949
Practice Address - Street 1:6040 S FORT APACHE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5613
Practice Address - Country:US
Practice Address - Phone:702-476-4900
Practice Address - Fax:702-476-4949
Is Sole Proprietor?:No
Enumeration Date:2018-12-14
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV815834363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2018070364OtherANCC
NV815834OtherAPRN LICENSE