Healthcare Provider Details

I. General information

NPI: 1447206529
Provider Name (Legal Business Name): ADDIE RODERICK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S DELAWARE DR STE 2
APACHE JUNCTION AZ
85120-6512
US

IV. Provider business mailing address

105 S DELAWARE DR STE 1
APACHE JUNCTION AZ
85120-6512
US

V. Phone/Fax

Practice location:
  • Phone: 480-646-1001
  • Fax: 480-646-1002
Mailing address:
  • Phone: 480-646-1001
  • Fax: 480-646-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN6179
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3930
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: