Healthcare Provider Details

I. General information

NPI: 1750145199
Provider Name (Legal Business Name): THERESIA FOMECHE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11003 N 59TH DR
GLENDALE AZ
85304-3744
US

IV. Provider business mailing address

11003 N 59TH DR
GLENDALE AZ
85304-3744
US

V. Phone/Fax

Practice location:
  • Phone: 520-991-6380
  • Fax:
Mailing address:
  • Phone: 520-991-6380
  • Fax: 602-584-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN176402
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: