Healthcare Provider Details

I. General information

NPI: 1164522900
Provider Name (Legal Business Name): ERLA JANE DENHAM LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MAIN ST
CASA GRANDE AZ
85222-4820
US

IV. Provider business mailing address

3765 S LA PALMA RD
COOLIDGE AZ
85228-9164
US

V. Phone/Fax

Practice location:
  • Phone: 520-836-1675
  • Fax: 520-421-1969
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP003991
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: