Healthcare Provider Details

I. General information

NPI: 1861506370
Provider Name (Legal Business Name): AMY LARISSA DEDEA PHARMD, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12075 AZ-69
DEWEY AZ
86327
US

IV. Provider business mailing address

85 CANYON TRL
SEDONA AZ
86351-7705
US

V. Phone/Fax

Practice location:
  • Phone: 928-772-1673
  • Fax:
Mailing address:
  • Phone: 928-773-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS018219
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS38830
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2405
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: