Healthcare Provider Details

I. General information

NPI: 1417082553
Provider Name (Legal Business Name): THERESA DOWELL P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 10/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S YALE ST STE# 252
FLAGSTAFF AZ
86001-7304
US

IV. Provider business mailing address

1515 E CEDAR AVE STE C-1
FLAGSTAFF AZ
86004-1637
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-1811
  • Fax: 928-774-2006
Mailing address:
  • Phone: 928-774-1811
  • Fax: 928-774-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4741
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3278
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: