Provider Demographics
NPI:1902587181
Name:MAIORA AESTHETICS & WELLNESS
Entity type:Organization
Organization Name:MAIORA AESTHETICS & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:IDICA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-BC
Authorized Official - Phone:808-341-6764
Mailing Address - Street 1:12427 PINETINA ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141
Mailing Address - Country:US
Mailing Address - Phone:808-341-6764
Mailing Address - Fax:
Practice Address - Street 1:5660 W.FLAMINGO RD.
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103
Practice Address - Country:US
Practice Address - Phone:702-423-1663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty