Healthcare Provider Details

I. General information

NPI: 1972962082
Provider Name (Legal Business Name): DELIA CONSENTINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1632 E FLOWER ST
PHOENIX AZ
85016-7115
US

IV. Provider business mailing address

4825 W DESERT HILLS DR
GLENDALE AZ
85304-2932
US

V. Phone/Fax

Practice location:
  • Phone: 623-256-0021
  • Fax:
Mailing address:
  • Phone: 623-256-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberLISAC 11466
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: