Healthcare Provider Details

I. General information

NPI: 1467701664
Provider Name (Legal Business Name): AMANDA IRIS CHACONAS DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA IRIS VERCOE

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W UNIVERSITY AVE STE 206
FLAGSTAFF AZ
86001-2996
US

IV. Provider business mailing address

1016 W UNIVERSITY AVE STE 206
FLAGSTAFF AZ
86001-2996
US

V. Phone/Fax

Practice location:
  • Phone: 928-226-1530
  • Fax:
Mailing address:
  • Phone: 928-226-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberTEMP281408
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN172540
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: