Healthcare Provider Details

I. General information

NPI: 1326642372
Provider Name (Legal Business Name): IDENTITY HORMONES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CAMELBACK RD STE 108
PHOENIX AZ
85012-1061
US

IV. Provider business mailing address

100 E CAMELBACK RD STE 108
PHOENIX AZ
85012-1061
US

V. Phone/Fax

Practice location:
  • Phone: 901-757-3643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA WILKINSON
Title or Position: BUSINESS OPERATIONS DIRECTOR
Credential:
Phone: 702-818-0446