Healthcare Provider Details

I. General information

NPI: 1851842447
Provider Name (Legal Business Name): MARY J BOOTZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY J O'BRIEN

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 E PECOS RD STE 215
GILBERT AZ
85295-3202
US

IV. Provider business mailing address

840 E MCKELLIPS RD STE 105
MESA AZ
85203-9654
US

V. Phone/Fax

Practice location:
  • Phone: 480-448-2411
  • Fax:
Mailing address:
  • Phone: 602-491-0701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8986
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: