Healthcare Provider Details

I. General information

NPI: 1982128351
Provider Name (Legal Business Name): MARY ANGELA CLOUSE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 E LINDA LN
GILBERT AZ
85234-6112
US

IV. Provider business mailing address

1922 E LINDA LN
GILBERT AZ
85234-6112
US

V. Phone/Fax

Practice location:
  • Phone: 480-290-3509
  • Fax:
Mailing address:
  • Phone: 480-290-3509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61372083
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberC-APN.0004738-C-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13396889-4405
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10428
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: