Healthcare Provider Details

I. General information

NPI: 1396521639
Provider Name (Legal Business Name): CLAUDIA SELENA CHACON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 N ARIZOLA RD
CASA GRANDE AZ
85122-6011
US

IV. Provider business mailing address

133 W HAWAII DR
CASA GRANDE AZ
85122-4957
US

V. Phone/Fax

Practice location:
  • Phone: 520-208-3178
  • Fax:
Mailing address:
  • Phone: 520-208-3178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number221483
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: