Healthcare Provider Details

I. General information

NPI: 1619754025
Provider Name (Legal Business Name): MYA THEDA KYI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6036 N 19TH AVE STE 202
PHOENIX AZ
85015-2104
US

IV. Provider business mailing address

6036 N 19TH AVE STE 202
PHOENIX AZ
85015-2104
US

V. Phone/Fax

Practice location:
  • Phone: 480-863-6328
  • Fax: 480-805-8818
Mailing address:
  • Phone: 480-863-6328
  • Fax: 480-805-8818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95023819
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number341609
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: