Healthcare Provider Details

I. General information

NPI: 1639919699
Provider Name (Legal Business Name): CHRISTA JEAN WILLIAMS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTA JEAN DODGEN

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19646 N 27TH AVE STE 305
PHOENIX AZ
85027-4027
US

IV. Provider business mailing address

5645 W RAINWATER DR
LAVEEN AZ
85339-5705
US

V. Phone/Fax

Practice location:
  • Phone: 480-556-0446
  • Fax:
Mailing address:
  • Phone: 702-726-1904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number268982
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: