Healthcare Provider Details

I. General information

NPI: 1659188464
Provider Name (Legal Business Name): MARILYN MADERA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 S RIVERPOINT PKWY
PHOENIX AZ
85040-0723
US

IV. Provider business mailing address

4025 S RIVERPOINT PKWY
PHOENIX AZ
85040-0723
US

V. Phone/Fax

Practice location:
  • Phone: 844-937-8679
  • Fax:
Mailing address:
  • Phone: 844-937-8679
  • Fax: 844-937-8679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number317440
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: