Healthcare Provider Details

I. General information

NPI: 1457235558
Provider Name (Legal Business Name): DALE TENNYSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 08/01/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N7, CORNER OF ROUTES N12& FORT DEFIANCE
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

28394 N 132ND AVE
PEORIA AZ
85383-2259
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN182166
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: