Healthcare Provider Details

I. General information

NPI: 1497575039
Provider Name (Legal Business Name): MARY ELIZABETH MYLCHREEST APRN (FNP-C)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ELIZABETH GRADES RN

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19829 N 27TH AVE
PHOENIX AZ
85027-4001
US

IV. Provider business mailing address

19636 N 27TH AVE STE 408
PHOENIX AZ
85027-4021
US

V. Phone/Fax

Practice location:
  • Phone: 623-879-6100
  • Fax:
Mailing address:
  • Phone: 623-780-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number317303
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License NumberRN203810
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: