Basic Information
| Provider Information | |||||||||
| NPI: | 1205021474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | MINNIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANCELLARO | ||||||||
| OtherFirstName: | MINNIE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 S 4TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891041046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023808118 | ||||||||
| FaxNumber: | 7023802929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 S 4TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891041046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023808118 | ||||||||
| FaxNumber: | 7023802929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 661205 | CA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 17447 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LC1500X | APRN001647 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health |
No ID Information.