Healthcare Provider Details

I. General information

NPI: 1063951614
Provider Name (Legal Business Name): PATRICIA MAYBORNE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N 24TH ST STE 100
PHOENIX AZ
85008-4645
US

IV. Provider business mailing address

1401 N 24TH ST STE 100
PHOENIX AZ
85008-4645
US

V. Phone/Fax

Practice location:
  • Phone: 602-844-7246
  • Fax: 602-759-7246
Mailing address:
  • Phone: 602-844-7246
  • Fax: 602-759-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP9657
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP9657
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: