Healthcare Provider Details

I. General information

NPI: 1114551603
Provider Name (Legal Business Name): FAUNTILY SKAGGS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 W INDIAN SCHOOL RD STE 102
BUCKEYE AZ
85396-2078
US

IV. Provider business mailing address

261 N ROOSEVELT AVE
CHANDLER AZ
85226-2616
US

V. Phone/Fax

Practice location:
  • Phone: 480-677-8282
  • Fax:
Mailing address:
  • Phone: 623-214-2200
  • Fax: 623-214-2208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number239740
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number239740
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: