Provider Demographics
NPI:1134861123
Name:REYES, MARLON ROA (MSN PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:ROA
Last Name:REYES
Suffix:
Gender:M
Credentials:MSN PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S JONES BLVD # 1109
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2623
Mailing Address - Country:US
Mailing Address - Phone:702-840-8518
Mailing Address - Fax:
Practice Address - Street 1:1225 W 190TH ST STE 280
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4305
Practice Address - Country:US
Practice Address - Phone:310-515-8113
Practice Address - Fax:310-538-2102
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11019279363LP0808X
NV852172363LP0808X
CA95020637363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty