Healthcare Provider Details

I. General information

NPI: 1528584547
Provider Name (Legal Business Name): NYANYIWA VIMBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E VAN BUREN ST
PHOENIX AZ
85008
US

IV. Provider business mailing address

PO BOX 52109
PHOENIX AZ
85072-2109
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-3100
  • Fax:
Mailing address:
  • Phone: 602-685-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5009803
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number219411
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: