Healthcare Provider Details

I. General information

NPI: 1336174903
Provider Name (Legal Business Name): NICOLE E STOVALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

3225 E ELWOOD ST STE. 110
PHOENIX AZ
85034-7259
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-1516
  • Fax: 602-344-1004
Mailing address:
  • Phone: 602-470-5000
  • Fax: 602-328-2115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberD64202
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: