Healthcare Provider Details

I. General information

NPI: 1164908414
Provider Name (Legal Business Name): ANDREA LEIGH FARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24654 N LAKE PLEASANT PKWY STE 103-715
PEORIA AZ
85383-1359
US

IV. Provider business mailing address

24654 N LAKE PLEASANT PKWY STE 103-715
PEORIA AZ
85383-1359
US

V. Phone/Fax

Practice location:
  • Phone: 623-399-9891
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN124247
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number219370
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: