Provider Demographics
NPI:1457772741
Name:BANUELOS, MICHELLE LEIGH
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGH
Last Name:BANUELOS
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 1:1050 E FLAMINGO RD # S107
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-7427
Mailing Address - Country:US
Mailing Address - Phone:775-751-6758
Mailing Address - Fax:775-751-6759
Practice Address - Street 1:1050 E FLAMINGO RD # S107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7427
Practice Address - Country:US
Practice Address - Phone:775-751-6758
Practice Address - Fax:775-751-6759
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker