Healthcare Provider Details

I. General information

NPI: 1639002868
Provider Name (Legal Business Name): QUEEN OKORONKWO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7655 W MARY JANE LN
PEORIA AZ
85382-3842
US

IV. Provider business mailing address

7655 W MARY JANE LN
PEORIA AZ
85382-3842
US

V. Phone/Fax

Practice location:
  • Phone: 602-545-7853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number267020
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: