Provider Demographics
NPI:1588908628
Name:CRUZ, JACINTA FAYO (APN)
Entity type:Individual
Prefix:MS
First Name:JACINTA
Middle Name:FAYO
Last Name:CRUZ
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11035 LAVENDER HILL DR STE 160-441
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-2955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5536 S FORT APACHE RD STE 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7687
Practice Address - Country:US
Practice Address - Phone:702-915-7001
Practice Address - Fax:702-909-9254
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVTAPN700839363LF0000X
NVAPRN001459363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1588908628Medicaid
NVV109118Medicare PIN