Healthcare Provider Details

I. General information

NPI: 1124543244
Provider Name (Legal Business Name): SHELLY MARIE ERICKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

19755 E WILLOW DR
QUEEN CREEK AZ
85142-9430
US

V. Phone/Fax

Practice location:
  • Phone: 480-515-6296
  • Fax:
Mailing address:
  • Phone: 480-209-4631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP10486
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10486
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: