Provider Demographics
NPI:1548229768
Name:DETIE, ANGELA REGINA (APN,CNM)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:REGINA
Last Name:DETIE
Suffix:
Gender:F
Credentials:APN,CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8480 S EASTERN AVE STE F
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-2822
Mailing Address - Country:US
Mailing Address - Phone:702-914-6900
Mailing Address - Fax:702-914-6904
Practice Address - Street 1:8480 S EASTERN AVE STE F
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2822
Practice Address - Country:US
Practice Address - Phone:702-914-6900
Practice Address - Fax:702-914-6904
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPN0512367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002402016Medicaid
NV151678OtherNEVADACARE PROVIDER ID
NVCC8630OtherANTHEM BC/BS PROVIDER ID
NV151678OtherNEVADACARE PROVIDER ID