Healthcare Provider Details

I. General information

NPI: 1114450962
Provider Name (Legal Business Name): JODI LYN LAY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 W OLIVE AVE STE 102
GLENDALE AZ
85302-3147
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 623-387-3705
  • Fax: 866-941-5662
Mailing address:
  • Phone: 602-509-9177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10016
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberAP10016
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: