Healthcare Provider Details

I. General information

NPI: 1265244115
Provider Name (Legal Business Name): EDWARD CAUDILL MSN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11022 N 28TH DR STE 270
PHOENIX AZ
85029-5639
US

IV. Provider business mailing address

11022 N 28TH DR STE 270
PHOENIX AZ
85029-5639
US

V. Phone/Fax

Practice location:
  • Phone: 623-404-8505
  • Fax: 602-429-8475
Mailing address:
  • Phone: 623-404-8505
  • Fax: 602-429-8475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number253121
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: