Healthcare Provider Details

I. General information

NPI: 1376595843
Provider Name (Legal Business Name): GEORGETTE MEHALIK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GEORGETTE M MISIEWICZ APRN

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13395 N MARANA MAIN ST
MARANA AZ
85653-7008
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-682-4111
  • Fax: 520-682-3817
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-818-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number034561-23
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP6435
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: