Healthcare Provider Details

I. General information

NPI: 1548723000
Provider Name (Legal Business Name): STEPHANIE NICHOLE O'CONNOR PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 S OCOTILLO AVE
BENSON AZ
85602-6406
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-4040
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-6852
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number224631
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: