Healthcare Provider Details

I. General information

NPI: 1730778648
Provider Name (Legal Business Name): EMMA MARIE STEPHENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18422 W ROMA AVE
GOODYEAR AZ
85395-6462
US

IV. Provider business mailing address

1345 E MAIN ST
MESA AZ
85203-8947
US

V. Phone/Fax

Practice location:
  • Phone: 602-573-9537
  • Fax:
Mailing address:
  • Phone: 480-404-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number251899
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number251899
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: