Healthcare Provider Details

I. General information

NPI: 1578379244
Provider Name (Legal Business Name): CONNIE RENEE GRESLY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 11/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4434 W TIERRA BUENA LN
GLENDALE AZ
85306-2704
US

IV. Provider business mailing address

4434 W TIERRA BUENA LN
GLENDALE AZ
85306-2704
US

V. Phone/Fax

Practice location:
  • Phone: 602-486-9318
  • Fax:
Mailing address:
  • Phone: 602-486-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number259593
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: