Healthcare Provider Details

I. General information

NPI: 1366015067
Provider Name (Legal Business Name): PRIYA SABUMON BALAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6677 W THUNDERBIRD RD STE I164
GLENDALE AZ
85306-3762
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD STE I164
GLENDALE AZ
85306-3762
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2100
  • Fax: 623-776-9419
Mailing address:
  • Phone: 623-878-2100
  • Fax: 623-776-9419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN214133
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number271815
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number271815
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number271815
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: