Healthcare Provider Details

I. General information

NPI: 1568089878
Provider Name (Legal Business Name): JUSTINE LYNN HUMPHREY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 E OAKWOOD HILLS DR
CHANDLER AZ
85248-6200
US

IV. Provider business mailing address

15 E OAKWOOD HILLS DR
CHANDLER AZ
85248-6200
US

V. Phone/Fax

Practice location:
  • Phone: 480-285-5105
  • Fax:
Mailing address:
  • Phone: 480-285-5105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: