Provider Demographics
NPI:1801263868
Name:STORY-SALACUP, JENNIFER (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STORY-SALACUP
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 1:2110 E FLAMINGO RD STE 105
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5191
Mailing Address - Country:US
Mailing Address - Phone:702-695-2084
Mailing Address - Fax:702-537-0981
Practice Address - Street 1:2110 E FLAMINGO RD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5191
Practice Address - Country:US
Practice Address - Phone:702-695-2084
Practice Address - Fax:702-537-0981
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001992363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1801263868Medicaid
NV1801263868Medicaid