Healthcare Provider Details

I. General information

NPI: 1013120419
Provider Name (Legal Business Name): DEER VALLEY USD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2816 W. WHITMAN CT
ANTHEM AZ
85086
US

IV. Provider business mailing address

2816 W. WHITMAN CT
ANTHEM AZ
85086
US

V. Phone/Fax

Practice location:
  • Phone: 623-551-8123
  • Fax:
Mailing address:
  • Phone: 623-551-8123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN123495
License Number StateAZ

VIII. Authorized Official

Name: CAROL WELLS
Title or Position: COORDINATOR
Credential:
Phone: 623-445-4952