Healthcare Provider Details

I. General information

NPI: 1609194737
Provider Name (Legal Business Name): BONNIE GANCE-CLEVELAND PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 05/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NORTH 3RD ST SUITE 155
PHOENIX AZ
85004-0698
US

IV. Provider business mailing address

500 N 3RD ST MAILCODE 3020
PHOENIX AZ
85004-2135
US

V. Phone/Fax

Practice location:
  • Phone: 602-496-0721
  • Fax:
Mailing address:
  • Phone: 602-496-0908
  • Fax: 602-496-0986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN139505
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP3039
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: