Provider Demographics
NPI:1548714520
Name:LANDICHO, PRUDENCE
Entity type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:
Last Name:LANDICHO
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 1:7985 MERLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7646
Mailing Address - Country:US
Mailing Address - Phone:702-526-7677
Mailing Address - Fax:702-586-0643
Practice Address - Street 1:4062 MONTHILL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-6318
Practice Address - Country:US
Practice Address - Phone:702-451-3284
Practice Address - Fax:702-451-3284
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV63ADZ-18175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath