Healthcare Provider Details

I. General information

NPI: 1437669504
Provider Name (Legal Business Name): CAROLINE BINGHAM AGPC-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12075 AZ STATE ROUTE 69
DEWEY AZ
86327
US

IV. Provider business mailing address

12075 AZ STATE ROUTE 69
DEWEY AZ
86327
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-1673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN210224
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP10622
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP10622
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP10622
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: