Healthcare Provider Details

I. General information

NPI: 1306958699
Provider Name (Legal Business Name): CHRISTINE SEVERANCE CARDONA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19841 N. 27TH AVENUE SUITE 101
PHOENIX AZ
85027-4002
US

IV. Provider business mailing address

19841 N. 27TH AVENUE SUITE 101
PHOENIX AZ
85027-4002
US

V. Phone/Fax

Practice location:
  • Phone: 602-942-8512
  • Fax: 602-942-1075
Mailing address:
  • Phone: 602-942-8512
  • Fax: 602-942-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A9613
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number005319
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: