Healthcare Provider Details

I. General information

NPI: 1477708071
Provider Name (Legal Business Name): JAMES TERRY BALLENTINE CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N CENTRAL AVE # 201
PHOENIX AZ
85004-1808
US

IV. Provider business mailing address

2929 E THOMAS RD
PHOENIX AZ
85016-8034
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-6550
  • Fax:
Mailing address:
  • Phone: 602-470-5000
  • Fax: 602-470-5064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP7090
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: