Healthcare Provider Details

I. General information

NPI: 1740518190
Provider Name (Legal Business Name): AMY T AN CNM, ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4344 E PRESIDIO ST
MESA AZ
85215-1143
US

IV. Provider business mailing address

4344 E PRESIDIO ST
MESA AZ
85215-1143
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-5111
  • Fax: 480-834-5222
Mailing address:
  • Phone: 480-834-5111
  • Fax: 480-834-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAP8927
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number96957
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP8927
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number96957
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: