Healthcare Provider Details

I. General information

NPI: 1538700059
Provider Name (Legal Business Name): LAY FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 W PEORIA AVE STE 115A
GLENDALE AZ
85302-2020
US

IV. Provider business mailing address

PO BOX 406
LAVEEN AZ
85339-0406
US

V. Phone/Fax

Practice location:
  • Phone: 602-509-9177
  • Fax: 480-666-6287
Mailing address:
  • Phone: 480-431-5067
  • Fax: 480-666-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JODI LAY
Title or Position: OWNER AND PROVIDER
Credential: FNP-C
Phone: 602-509-9177