Healthcare Provider Details

I. General information

NPI: 1144925306
Provider Name (Legal Business Name): JAIME KOENIG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 E IRVINE RD
PHOENIX AZ
85086-9319
US

IV. Provider business mailing address

905 E IRVINE RD
PHOENIX AZ
85086-9319
US

V. Phone/Fax

Practice location:
  • Phone: 623-205-1811
  • Fax:
Mailing address:
  • Phone: 623-205-1811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN128059
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberRNP294590
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: