Healthcare Provider Details

I. General information

NPI: 1992587877
Provider Name (Legal Business Name): ROSIE JARI MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1929 W FILLMORE ST BLDG C
PHOENIX AZ
85009-3812
US

IV. Provider business mailing address

1929 W FILLMORE ST BLDG C
PHOENIX AZ
85009-3812
US

V. Phone/Fax

Practice location:
  • Phone: 602-258-6008
  • Fax: 602-258-8388
Mailing address:
  • Phone: 602-258-6008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number312190
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: