Basic Information
| Provider Information | |||||||||
| NPI: | 1548229768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETIE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | REGINA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APN,CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9260 W SUNSET RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891484858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022553547 | ||||||||
| FaxNumber: | 7029212419 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 N TENAYA WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022553547 | ||||||||
| FaxNumber: | 7023072204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | APN0512 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 002402016 | 05 | NV | MEDICAID | 151678 | 01 | NV | NEVADACARE PROVIDER ID | OTHER | CC8630 | 01 | NV | ANTHEM BC/BS PROVIDER ID | OTHER |