Healthcare Provider Details

I. General information

NPI: 1538630280
Provider Name (Legal Business Name): JESSICA L SEGURA GUERRERO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 N 108TH AVE STE 105
PHOENIX AZ
85037-5772
US

IV. Provider business mailing address

4110 N 108TH AVE STE 105
PHOENIX AZ
85037-5772
US

V. Phone/Fax

Practice location:
  • Phone: 699-962-3772
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number219542
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: