Provider Demographics
NPI:1912492794
Name:MUNDLE, NYOKA PETA-GAYE
Entity Type:Individual
Prefix:
First Name:NYOKA
Middle Name:PETA-GAYE
Last Name:MUNDLE
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 1:4616 W SAHARA AVE STE 394
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-3654
Mailing Address - Country:US
Mailing Address - Phone:347-931-7206
Mailing Address - Fax:
Practice Address - Street 1:875 E SILVERADO RANCH BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-5887
Practice Address - Country:US
Practice Address - Phone:347-931-7206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLPN14518164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse