Healthcare Provider Details

I. General information

NPI: 1649496829
Provider Name (Legal Business Name): DOROTHEA BLANCHE STEVENS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MEDICINE WAY
PERIDOT AZ
85542
US

IV. Provider business mailing address

PO BOX 444
PERIDOT AZ
85542
US

V. Phone/Fax

Practice location:
  • Phone: 928-475-1540
  • Fax: 928-475-1571
Mailing address:
  • Phone: 602-908-5573
  • Fax: 928-475-1571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN035543
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN035543
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN035543
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: