Provider Demographics
NPI:1306612452
Name:CRUZ, DAUGHERTY IZAR
Entity type:Individual
Prefix:
First Name:DAUGHERTY
Middle Name:IZAR
Last Name:CRUZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1820 SUNLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3969
Mailing Address - Country:US
Mailing Address - Phone:702-401-1692
Mailing Address - Fax:
Practice Address - Street 1:9550 S EASTERN AVE STE 253
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-8042
Practice Address - Country:US
Practice Address - Phone:702-728-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner