Provider Demographics
NPI:1144860057
Name:CORONADO, CHARMAINE LOU
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:LOU
Last Name:CORONADO
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 1:9835 RAVEN WING CANYON CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-6315
Mailing Address - Country:US
Mailing Address - Phone:702-622-2776
Mailing Address - Fax:
Practice Address - Street 1:5410 W SAHARA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3307
Practice Address - Country:US
Practice Address - Phone:702-362-2500
Practice Address - Fax:702-876-6581
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN52818163W00000X
NV826962363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV826962OtherNV STATE BOARD OF NURSING