Provider Demographics
NPI:1720818438
Name:MALLANTA, KRIZELLE QUIAMBAO
Entity type:Individual
Prefix:
First Name:KRIZELLE
Middle Name:QUIAMBAO
Last Name:MALLANTA
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 1:808 PITTSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6725
Mailing Address - Country:US
Mailing Address - Phone:702-773-2017
Mailing Address - Fax:
Practice Address - Street 1:808 PITTSTON AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-6725
Practice Address - Country:US
Practice Address - Phone:702-773-2017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV881287363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily