Healthcare Provider Details

I. General information

NPI: 1467787861
Provider Name (Legal Business Name): BERTA LEIS PHD, ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2009
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 N 12TH ST UNIT 151
PHOENIX AZ
85014-1314
US

IV. Provider business mailing address

6333 N 12TH ST UNIT 151
PHOENIX AZ
85014-1314
US

V. Phone/Fax

Practice location:
  • Phone: 602-730-0307
  • Fax:
Mailing address:
  • Phone: 602-730-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP3180
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN053220
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: