Healthcare Provider Details

I. General information

NPI: 1063975076
Provider Name (Legal Business Name): DIANA THAYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 E THOMAS RD STE 200
PHOENIX AZ
85016
US

IV. Provider business mailing address

1910 E THOMAS RD STE 200
PHOENIX AZ
85016-7767
US

V. Phone/Fax

Practice location:
  • Phone: 602-266-2200
  • Fax: 602-604-5032
Mailing address:
  • Phone: 602-266-2200
  • Fax: 602-604-5032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRNP223586
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRNP223586
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRNP223586
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRNP223586
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: