Healthcare Provider Details

I. General information

NPI: 1386210508
Provider Name (Legal Business Name): AGAVE POSTPARTUM WELLNESS CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21725 N 20TH AVE SUITE 101-102 #1019
PHOENIX AZ
85027-2640
US

IV. Provider business mailing address

21725 N 20TH AVE SUITE 101-102 #1019
PHOENIX AZ
85027-2640
US

V. Phone/Fax

Practice location:
  • Phone: 602-384-1648
  • Fax:
Mailing address:
  • Phone: 602-384-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: INTY ALLEN
Title or Position: OWNER/PROVIDER
Credential: FNP
Phone: 602-384-1648