Basic Information
| Provider Information | |||||||||
| NPI: | 1093284218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHULTIS | ||||||||
| FirstName: | LINDIANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6355 S BUFFALO DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891132133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1397 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | PAHRUMP | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890484729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757275500 | ||||||||
| FaxNumber: | 7757275696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2018 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F10181775 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 815636 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 815636 | 01 | NV | STATE LICENSE | OTHER | 1093284218 | 05 | NV | MEDICAID |