Provider Demographics
NPI:1760952360
Name:HUNTLY, MARY BRIDGET (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BRIDGET
Last Name:HUNTLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 W SAHARA AVE STE D104
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-0846
Mailing Address - Country:US
Mailing Address - Phone:725-205-2457
Mailing Address - Fax:725-240-7742
Practice Address - Street 1:6655 W SAHARA AVE STE D104
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146
Practice Address - Country:US
Practice Address - Phone:725-205-2457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV815069163WW0000X
NVF09180993363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WW0000XNursing Service ProvidersRegistered NurseWound Care