Healthcare Provider Details

I. General information

NPI: 1376225763
Provider Name (Legal Business Name): JENNIFER NODERAMA FACURIB APRN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 S DOBSON RD STE 214
CHANDLER AZ
85224
US

IV. Provider business mailing address

3333 E CAMELBACK RD STE 180
PHOENIX AZ
85018-2396
US

V. Phone/Fax

Practice location:
  • Phone: 480-857-2381
  • Fax: 480-857-2407
Mailing address:
  • Phone: 602-759-6883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number295649
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number295649
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: