Healthcare Provider Details

I. General information

NPI: 1245357672
Provider Name (Legal Business Name): SUSAN MAY DISILVESTRO LM CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E BETHANY HOME RD SUITE A115
PHOENIX AZ
85012-1263
US

IV. Provider business mailing address

21122 S GREENFIELD RD
CHANDLER AZ
85249-9414
US

V. Phone/Fax

Practice location:
  • Phone: 602-799-4455
  • Fax: 602-263-8779
Mailing address:
  • Phone: 602-799-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM131
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: