Provider Demographics
NPI:1891519120
Name:LICUDO, TARABEL SHANTEL ALVAREZ
Entity type:Individual
Prefix:
First Name:TARABEL SHANTEL
Middle Name:ALVAREZ
Last Name:LICUDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARABEL
Other - Middle Name:SHANTEL
Other - Last Name:ALVAREZ-AMADOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 PILOT RD STE 250
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-3514
Mailing Address - Country:US
Mailing Address - Phone:702-982-3292
Mailing Address - Fax:
Practice Address - Street 1:250 PILOT RD STE 250
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3514
Practice Address - Country:US
Practice Address - Phone:702-982-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV881693163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health