Healthcare Provider Details

I. General information

NPI: 1669376265
Provider Name (Legal Business Name): DESIRE ALEXIS COLLISTER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1863 E FLORENCE BLVD
CASA GRANDE AZ
85122
US

IV. Provider business mailing address

240 S SAN JOSE LN
CASA GRANDE AZ
85194-7413
US

V. Phone/Fax

Practice location:
  • Phone: 520-836-3446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number260568
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: