Healthcare Provider Details

I. General information

NPI: 1306330105
Provider Name (Legal Business Name): MRS. BRANDY COLLIEN BAUER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42419 N CENTRAL AVE
PHOENIX AZ
85086-7571
US

IV. Provider business mailing address

42419 N CENTRAL AVE
PHOENIX AZ
85086-7571
US

V. Phone/Fax

Practice location:
  • Phone: 602-770-3770
  • Fax:
Mailing address:
  • Phone: 602-770-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number219004
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License NumberRN129694
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: