Healthcare Provider Details

I. General information

NPI: 1700398898
Provider Name (Legal Business Name): ELISABETH JANE FOSTINO MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BETSY BRADSHAW

II. Dates (important events)

Enumeration Date: 10/29/2017
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15640 N 28TH DR
PHOENIX AZ
85053-4059
US

IV. Provider business mailing address

15136 W WASHINGTON ST
GOODYEAR AZ
85338-6909
US

V. Phone/Fax

Practice location:
  • Phone: 217-439-9000
  • Fax: 602-978-5233
Mailing address:
  • Phone: 217-853-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number259849
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: