Healthcare Provider Details

I. General information

NPI: 1407460983
Provider Name (Legal Business Name): ELI FORYANG MBEUFONJOH PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S 7TH AVE
PHOENIX AZ
85007-3913
US

IV. Provider business mailing address

965 S WALLRADE LN
GILBERT AZ
85296-1494
US

V. Phone/Fax

Practice location:
  • Phone: 602-416-7600
  • Fax:
Mailing address:
  • Phone: 908-477-3144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberR217419
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number256548
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: