Healthcare Provider Details

I. General information

NPI: 1366860843
Provider Name (Legal Business Name): KANIZ FATEMA ISLAM FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5099 W DOBBINS RD
LAVEEN AZ
85339-9733
US

IV. Provider business mailing address

5209 W SIESTA WAY
LAVEEN AZ
85339-7179
US

V. Phone/Fax

Practice location:
  • Phone: 602-352-9898
  • Fax: 949-247-5542
Mailing address:
  • Phone: 602-550-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAZ5476
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAZ5476
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN154095
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: