Healthcare Provider Details

I. General information

NPI: 1548698913
Provider Name (Legal Business Name): AMY FIFE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 E WARNER RD STE 115
GILBERT AZ
85296-3056
US

IV. Provider business mailing address

690 E WARNER RD STE 115
GILBERT AZ
85296-3056
US

V. Phone/Fax

Practice location:
  • Phone: 480-444-2434
  • Fax:
Mailing address:
  • Phone: 480-444-2434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-14278
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: