Healthcare Provider Details

I. General information

NPI: 1316997349
Provider Name (Legal Business Name): CYNTHIA J SHIVELY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

IV. Provider business mailing address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

V. Phone/Fax

Practice location:
  • Phone: 602-996-4747
  • Fax: 602-953-5466
Mailing address:
  • Phone: 602-996-4747
  • Fax: 602-953-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4137
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN115612
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: