Healthcare Provider Details

I. General information

NPI: 1396490280
Provider Name (Legal Business Name): NADIA DRAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NADIA WILLOUGHBY DRAKE MBA

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12020 S WARNER ELLIOT LOOP STE 124
PHOENIX AZ
85044-2717
US

IV. Provider business mailing address

3702 E CAMELBACK RD
PHOENIX AZ
85018-2508
US

V. Phone/Fax

Practice location:
  • Phone: 480-744-1950
  • Fax:
Mailing address:
  • Phone: 480-648-6446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number03D2212772
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: