Basic Information
| Provider Information | |||||||||
| NPI: | 1396293841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | SHANDREKA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N STEPHANIE ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890146692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029523356 | ||||||||
| FaxNumber: | 7029523364 | ||||||||
| Practice Location | |||||||||
| Address1: | 10001 S EASTERN AVE STE 108 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029523444 | ||||||||
| FaxNumber: | 7029523494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2016 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 821513 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.