Healthcare Provider Details

I. General information

NPI: 1629887260
Provider Name (Legal Business Name): AMBER VAN DAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 04/09/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

IV. Provider business mailing address

12544 W ALEGRE DR
LITCHFIELD PARK AZ
85340-5540
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-5900
  • Fax:
Mailing address:
  • Phone: 708-207-2134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number237509
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number237509
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: