Healthcare Provider Details

I. General information

NPI: 1508366402
Provider Name (Legal Business Name): SERENA DAWN ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17500 N 67TH AVE APT 1043
GLENDALE AZ
85308-1081
US

IV. Provider business mailing address

18275 N 59TH AVE STE 138
GLENDALE AZ
85308-1253
US

V. Phone/Fax

Practice location:
  • Phone: 480-620-6435
  • Fax:
Mailing address:
  • Phone: 602-564-0078
  • Fax: 602-564-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10959
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: