Healthcare Provider Details

I. General information

NPI: 1104538180
Provider Name (Legal Business Name): LETICIA MORA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W THOMAS RD # 6NST
PHOENIX AZ
85013-4409
US

IV. Provider business mailing address

240 W THOMAS RD # 301
PHOENIX AZ
85013-4407
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3000
  • Fax:
Mailing address:
  • Phone: 602-406-7765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number285068
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number285068
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: