Healthcare Provider Details

I. General information

NPI: 1164809893
Provider Name (Legal Business Name): JENNIFER RAE QUEZADA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W THOMAS RD STE 400
PHOENIX AZ
85013-4238
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-4786
  • Fax: 916-636-4358
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN161919
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP8094
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: