Healthcare Provider Details

I. General information

NPI: 1154016533
Provider Name (Legal Business Name): NICOLE JOSETTE BOARDMAN MITCHAM MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

IV. Provider business mailing address

8088 W WHITNEY DR
PEORIA AZ
85345-6564
US

V. Phone/Fax

Practice location:
  • Phone: 833-855-9973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number79944
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: