Healthcare Provider Details

I. General information

NPI: 1053883371
Provider Name (Legal Business Name): ELIZABETH VIDALES DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 E MONROE AVE
BUCKEYE AZ
85326-2706
US

IV. Provider business mailing address

3033 N CENTRAL AVE STE 145
PHOENIX AZ
85012-2808
US

V. Phone/Fax

Practice location:
  • Phone: 877-809-5092
  • Fax:
Mailing address:
  • Phone: 623-583-3001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number220228
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: