Healthcare Provider Details

I. General information

NPI: 1346962057
Provider Name (Legal Business Name): NOPALLI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 E AGAVE RD STE 148
PHOENIX AZ
85044-0623
US

IV. Provider business mailing address

PO BOX 61025
PHOENIX AZ
85082-1025
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-7546
  • Fax:
Mailing address:
  • Phone: 480-681-3300
  • Fax: 480-681-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE MEDINA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 480-681-3300