Healthcare Provider Details

I. General information

NPI: 1063332377
Provider Name (Legal Business Name): GINA DOREST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15815 S LAKEWOOD PKWY W APT 1065
PHOENIX AZ
85048-7289
US

IV. Provider business mailing address

15815 S LAKEWOOD PKWY W APT 1065
PHOENIX AZ
85048-7289
US

V. Phone/Fax

Practice location:
  • Phone: 602-491-1997
  • Fax:
Mailing address:
  • Phone: 602-491-1997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number338841
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: