Healthcare Provider Details

I. General information

NPI: 1346642204
Provider Name (Legal Business Name): CONNIE NIES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E PINCHOT AVE
PHOENIX AZ
85018-6807
US

IV. Provider business mailing address

202 E. EARLL DR. SUITE 200
PHOENIX AZ
85012-2647
US

V. Phone/Fax

Practice location:
  • Phone: 602-599-5532
  • Fax: 602-599-5711
Mailing address:
  • Phone: 602-808-2800
  • Fax: 602-599-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-054545
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: