Healthcare Provider Details

I. General information

NPI: 1962190066
Provider Name (Legal Business Name): DEVON MCCLUSKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6315 W PORT AU PRINCE LN
GLENDALE AZ
85306-3217
US

IV. Provider business mailing address

6315 W PORT AU PRINCE LN
GLENDALE AZ
85306-3217
US

V. Phone/Fax

Practice location:
  • Phone: 623-412-4550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number284699
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: