Healthcare Provider Details

I. General information

NPI: 1376407122
Provider Name (Legal Business Name): SOPHIE ENJEMA MBUA NDUMBE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13451 N 94TH DR
PEORIA AZ
85381-5056
US

IV. Provider business mailing address

11034 W HADLEY ST
AVONDALE AZ
85323-4563
US

V. Phone/Fax

Practice location:
  • Phone: 623-303-7101
  • Fax:
Mailing address:
  • Phone: 701-610-8059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number256331
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: