Healthcare Provider Details

I. General information

NPI: 1164892394
Provider Name (Legal Business Name): SUSAN BAILEY F-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 N 108TH AVE SUITE 134
PHOENIX AZ
85037-5466
US

IV. Provider business mailing address

20325 N 51ST AVE SUITE 160
GLENDALE AZ
85308-5674
US

V. Phone/Fax

Practice location:
  • Phone: 623-295-4901
  • Fax:
Mailing address:
  • Phone: 623-466-6350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8119
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: