Healthcare Provider Details

I. General information

NPI: 1386204097
Provider Name (Legal Business Name): CHEYENNA LYNNE KOPACZ DNP FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHEYENNA LYNNE KAWAL

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 09/21/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#1098 2501 W HAPPY VALLEY RD SUITE 4
PHOENIX AZ
85085
US

IV. Provider business mailing address

#1098 2501 W HAPPY VALLEY RD SUITE 4
PHOENIX AZ
85085
US

V. Phone/Fax

Practice location:
  • Phone: 602-489-4958
  • Fax:
Mailing address:
  • Phone: 602-489-4958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number227570
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: