Provider Demographics
NPI:1053778290
Name:PALACIO, ANDREA DIANE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:DIANE
Last Name:PALACIO
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 1:675 MARLBERRY PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7475
Mailing Address - Country:US
Mailing Address - Phone:702-626-6973
Mailing Address - Fax:
Practice Address - Street 1:675 MARLBERRY PL
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7475
Practice Address - Country:US
Practice Address - Phone:702-626-6973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV172V00000X
NVCNA017438376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No172V00000XOther Service ProvidersCommunity Health Worker